North Carolina Industrial Commission IC File # INTERVENOR222S REQUEST THAT CLAIM BE ASSIGNED FOR HEARING (N.C. GEN. STAT. 247 97-26(i)) FORM 33I 10/2017 PAGE 1 OF 1 FORM 33I FILE VIA EDFP OR E-MAIL TO DOCKETS@IC.NC.GOV OR MAIL TO CLERK222S OFFICE 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV A. INTERVENOR/MEDICAL PROVIDER INFORMATION Medical Provider Contact Name Date(s) of Service Address City State Zip ( ) - ( ) - Total Charges for Services Provided Telephone Fax Email B. EMPLOYEE/CLAIMANT C. EMPLOYER/CARRIER INFORMATION ( ) - Employee222s Name Employer222s Name Telephone Number Address Employer222s Address City State Zip City State Zip Insurance Carrier Policy Number ( ) - ( ) - Home Telephone Work Telephone Adjustor - - M F / / Social Security Number Sex Date of Birth Carrier222s Address City State Zip ( ) - ( ) - Carrier222s Telephone Number Carrier222s Fax Number The above-named Intervenor, files notice that, pursuant to N.C. Gen. Stat. 247 97-26(i) and Rule 24 of the North Carolina Rules of Civil Procedure, N.C. Gen. Stat. 247 1A-1, it has been allowed a limited intervention in this matter by Order dated . The Intervenor and the parties above have failed to resolve a dispute regarding payment of charges for medical services indicated above and request a hearing. Name of Individual Receiving Services: Date of Injury: Has Claim been: Admitted. Denied. Date of Denial: Has a compromise settlement agreement been approved? Yes No Date Approved: Has any party to this claim previously requested a hearing before the Industrial Commission? Yes No CERTIFICATION I, , hereby certify that this case is ready for hearing Print Name and request a hearing in Wake County or County. Signature of (Check One) Attorney, Medical Provider/Intervenor Date Note: A copy of this form must be sent to opposing parties. The original of this form must be sent to the Industrial Commission at the address below. American LegalNet, Inc. www.FormsWorkFlow.com