STATE OF NEW YORK WORKERS COMPENSATION BOARD Office of Health Provider Administration 1-800-781-2362 W C B D I S P U T E N U M B E R NOTICE TO CHAIR WORKERS COMPENSATION BOARD WITHDRAWAL OF REQUEST FOR ARBITRATION PLEASE TYPE OR PRINT THIS FORM IN BLACK OR BLUE INK ONLY. See other instructions on reverse. Outpatient Inpatient Physical Occupational TYPE OF CARE: Medical Chiropractic Psychology Podiatry Osteopathic Hospital Hospital Therapy Therapy Name and Mailing Address of Health Provider (MAXIMUM 30 CHARACTERS) Name WCB Lines 1&2 Dispute Address Number: Zip City State - Code Name and Billing Address of Health Provider (MAXIMUM 30 CHARACTERS) WCB Authorization Number Carrier or Self-Insured Employer I.D. Name Lines 1&2 WCB Case Number Carrier Case Number Address W City State Zip - Code Name and Mailing Address of Carrier (MAXIMUM 30 CHARACTERS) Claimants Social Security Number Date of Accident Name - - / / Lines 1&2 M M D D Y Y Name of Claimant (First, Middle Initial, Last Name) Address Zip City State Code - Name of Employer (MAXIMUM 30 CHARACTERS) Date Set For Hearing YES NO HAS THIS BILL(S) BEEN SCHEDULED FOR ARBITRATION PRIOR TO SUBMISSION OF THIS FORM? IF YES, GIVE DATE OF HEARING: / / M M D D Y YLIST BELOW BILL(S) THAT ARE BEING WITHDRAWN: A B C D (USE WCB CODE)E F G H I Date of Service Leave Leave Procedures, Services or Supplies Leave Leave Leave Blank (Explain Unusual Circumstances) Leave Blank Dollar Amount Agreed To Blank Blank $ Charges Blank MM DD YY CPT/HCPCS MODIFIER Blank 1. 2. 3. 4. 5. 6. 7 8 9 10 11 12 IS ARBITRATION NEEDED FOR OTHER BILLSYES NO LISTED ON HP-1 PREVIOUSLY SUBMITTED? We herewith certify that any dispute(s) associated with the above bill(s) has been resolved. Health Providers Signature Date Telephone No.HP-4 (4-05) Representative from Insurer Representatives Title Date Telephone No. THE WORKERS COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. American LegalNet, Inc. www.USCourtForms.com>>>> 2 FILING INSTRUCTIONS THIS ORIGINAL FORM SHOULD BE FILED IMMEDIATELY, BY THE INSURER, OR HEALTH PROVIDER, WITH THE: WORKERS COMPENSATION BOARD OFFICE OF HEALTH PROVIDER ADMINISTRATION 100 BROADWAY-MENANDS ALBANY, N.Y. 12241 WHEN THE FOLLOWING CONDITIONS EXIST: 1. BY THE INSURER - THE INSURER AND HEALTH PROVIDER HAVE RESOLVED PAYMENT DISPUTE(S) RELATED TO THE VALUE OF THE MEDICAL AID RENDERED BY THE PROVIDER; AND - THE BILL(S) RELATED TO THE RESOLVED DISPUTE(S) WERE PREVIOUSLY SUBMITTED TO THE DISPUTED BILL UNIT, ALBANY FOR ARBITRATION; AND - THE INSURER AND HEALTH PROVIDER HAVE AFFIRMED THEIR AGREEMENT TO THE WITHDRAWAL OF THESE BILL(S) FROM ARBITRATION BY SIGNING IN THE APPROPRIATE AREA ON THE FRONT OF THIS FORM. OR 2. BY THE HEALTH PROVIDER - THE HEALTH PROVIDER ON HIS/HER OWN VOLUNTARILY AGREES TO WITHDRAW THE BILL(S) FROM ARBITRATION BY SIGNING IN THE APPROPRIATE AREA ON THE FRONT OF THIS FORM. IMPORTANT NOTE IF THIS ORIGINAL FORM IS FILED WITH THE OFFICE OF HEALTH PROVIDER ADMINISTRATION LESS THAN 30 DAYS PRIOR TO THE INITIAL DATE THE RELATED BILL(S) IS SCHEDULED FOR ARBITRATION, THE HEALTH PROVIDER WILL BE RESPONSIBL E FOR THE PAYMENT OF THE ARBITRATION FEE. THE FEE WILL BE REFUNDED TO THE HEALTH PROVIDER IF THE BOARD IS NOTIFIED OF THE SETTLEMENT PRIOR TO THE 30 DAYS. HP-4 (4-05) Reverse American LegalNet, Inc. www.USCourtForms.com