NORTH CAROLINA INDUSTRIAL COMMISSION MEDICAL PROVIDER DISPUTE RESOLUTION QUESTIONNAIRE (N.C. GEN. STAT. §97-26(i)) Medical Provider MUST Complete Sections A-C Below A. MEDICAL PROVIDER INFORMATION Medical Provider Date(s) of Service Total Charges for Services Provided Contact Name Address City State Zip ( Email ) - ( ) Fax - Telephone The above named medical provider is seeking payment for the attached medical services provided in a workers' compensation claim. The medical provider has received information that the employer is Insured by the carrier listed below Self-insured Uninsured B. EMPLOYEE/CLAIMANT Employee's Name Address City State Zip IC File No C. EMPLOYER/CARRIER INFORMATION ( ) Employer's Name Employer's Address Insurance Carrier Adjustor Carrier's Address City State Zip City Telephone Number State Zip Policy Number ( - ) - Sex ( M F ) Work Telephone Home Telephone Social Security Number / / ( ) ( ) Carrier's Telephone Number Carrier's Fax Number Date of Birth Employer/Carrier MUST Complete Section D Below D. EMPLOYER/CARRIER RESPONSE The above named employer and/or workers' compensation insurance carrier must provide the information requested below regarding this case and the attached medical expenses to the above named medical provider within 20 days of receiving this questionnaire. The above named employer and/or workers' compensation insurance carrier: is not the employer or carrier for this claim. denies liability for this workers' compensation claim. Date of Denial: __________ admits liability for this workers' compensation claim. If liability admitted, do you accept liability for the attached medical expenses? Yes No If liability denied for this claim or the attached medical expenses, please explain: ___________________________ ________________________________________________________________________________ Has either party to this claim requested a hearing before the Industrial Commission? Yes No Has a compromise settlement agreement been approved? Yes No Date Approved: _________ ____________________________________________ Signature of (Check One) Employer, Attorney, Carrier Representative ____________ Date ____________________________________________ Print Name FORM 26I American LegalNet, Inc. www.FormsWorkFlow.com