DATE SPAN FOR ATTACHED BILL: to HEALTH PROVIDER'S REQUEST FOR DECISION ON UNPAID MEDICAL BILL(S)HP-1HP-1 Page 1 of 2 (2-18) Name and Mailing Address of Health Provider (MAXIMUM OF 30 CHARACTERS) Name Address City Zip Code StateName and Mailing Address of Employer (MAXIMUM OF 30 CHARACTERS) Name Address City Zip Code StateName and Mailing Address of Carrier (MAXIMUM OF 30 CHARACTERS) Name Address City Zip Code StateName and Billing Address of Health Provider (MAXIMUM OF 30 CHARACTERS) Name Address City Zip Code State WCB Case Number Provider's WCB Rating Code Provider's Telephone Number (include area code) Carrier Case Number WCB Authorization Number WCarrier or Self-Insured Employer ID #Date of Accident (mm/dd/yy)//Date You First Treated Claimant (mm/dd/yy)// Medical OutpatientHospital Occupational Therapy Chiropractic Osteopathic Psychology Podiatry Physical TherapyA.The medical bill(s) originally submitted on Form C-4, UB-04, CMS-1450 or CMS-1500 (with detailed narrative to the responsible carrier/self-insured employer); AND B. The medical bill(s) was timely submitted to the responsible insurance carrier or self-insured employer for payment. Timely submission of a bill is within 120 days for a hospital and 90 days for all other health providers from the last day of the month in which the service(s) was rendered or 90 days from the last day of the month in which the claimant receives the final treatment in a continuous course of treatment, whichever is later (and the bill was not returned by the post office); AND PROVIDER: CHECK ONLY ONE REQUEST BOX: (PLEASE TYPE OR PRINT THIS FORM IN BLACK OR BLUE INK ONLY)Carrier did not reply with Form C-8.4, nonpayment explanation, or payfor medical services submitted on the attached bill. More than 45 dayshave passed since the date of the medical bill submission or more than30 days from the receipt of a related notice establishing carrier/employerliability. Complete the front and Section A on the reverse of this form.DO NOT SUBMIT MORE THAN ONE BILL WITH THIS FORM.RETURN THIS ORIGINAL AND COMPLETED FORM TO: NYS Workers' Compensation Board PO Box 5205 Binghamton, NY 13902-5205 A.REQUEST FOR ADMINISTRATIVE AWARDCarrier has not satisfactorily paid for services rendered as shown on theattached medical bill(s). A copy of the carrier's payment explanation,including a copy of Form C-8.4, must be attached. If you wish to submitB.REQUEST FOR ARBITRATION NUMBER OF MEDICAL BILLS ATTACHEDTYPE OF CARE: County where Service was RenderedClaimant's Social Security Number- - Name of Claimant (First, Middle Initial, Last Name)I affirm, under penalty of perjury, that the conditions indicated above are true. Health Provider's Signature Date:Return this original and completed form with the required attachments to the Workers' Compensation Board when the conditions listed below exist. If you have any questions regarding the completion of this form, you may contact us at //// American LegalNet, Inc. www.FormsWorkFlow.com HP-1 Page 2 of 2 (2-18) Reversewww.wcb.ny.govSECTION A: REQUEST FOR ADMINISTRATIVE AWARD - PLEASE COMPLETE THE FOLLOWINGSECTION B: REQUEST FOR ARBITRATION - PLEASE COMPLETE THE FOLLOWING Health Provider's SignatureI certify that the foregoing bill(s) was originally submitted on Form C-4, UB-04, CMS-1450 or CMS-1500 (with detailed narrative) to the responsible carrier/self-insured employer for payment. Acceptable payment has not been received and arbitration is required. In the event the dispute is resolved by a single arbitrator or I fail to appear at a scheduled hearing, I will abide by the arbitration decision. Date: Federal Tax ID Number Amount in Dispute ($) Amount Paid ($) Total Charge ($) SSN EIN Federal Tax ID Number Amount Paid ($) Total Charge ($) Amount in Dispute ($) I hereby elect resolution of my claim greater than $1,000 by Desk Arbitration. A single arbitrator will conduct a review based on the parties' paper submissions. I hereby elect resolution of my claim greater than $1,000 by Panel Arbitration. A hearing will be scheduled at which parties may present arguments to an arbitration panel of two or more members. SSN EINANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.Amounts in Dispute of $1,000 or less: The Board automatically assigns any claim of $1,000 or less to Desk Arbitration. A single arbitrator makes a determination based on the parties' paper submissions.Amounts in Dispute Greater than $1,000: Providers with claims greater than $1,000 may elect resolution by Desk Arbitration or Panel Arbitration. Desk Arbitration allows for faster resolution. Disputes involving similar services are grouped for review by an appropriate arbitrator. The arbitrator makes a determination based on the parties' paper submissions. Parties do not have to appear at a hearing. Panel Arbitration is conducted at a hearing before a panel of two or more arbitrators. Parties appear at the hearing and present arguments to the arbitration panel. Please check one: American LegalNet, Inc. www.FormsWorkFlow.com