Provider Request For An Adjustment
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Provider Request For An Adjustment Form. This is a North Dakota form and can be use in Workers Comp.
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Tags: Provider Request For An Adjustment, SFN 58310, North Dakota Workers Comp,
1600 EAST CENTURY AVENUE, SUITE 1
PO BOX 5585
BISMARCK ND 58506-5585
Telephone 1-800-777-5033
Toll Free Fax 1-866-356-6433
TTY (hearing impaired) 1-800-366-6888
Fraud and Safety Hotline 1-800-243-3331
www.WorkforceSafety.com
PROVIDER REQUEST
FOR AN ADJUSTMENT
MEDICAL SERVICES DIVISION
SFN 58310 (01/2009)
INJURED WORKER INFORMATION
Patient’s Name
Claim Number
Bill Number
CMS 1500
UB
REASON FOR REQUEST
Medical Notes Attached
Underpayment
Retro Review (complete explanation section below)
Requesting reconsideration for payment (complete explanation section below)
PROVIDER INFORMATION
Provider’s Name
Provider’s Address
State
City
Federal Tax ID Number
Zip
Check Number
PAYMENT INFORMATION
Remittance Advice Date
DATES OF SERVICE
UNITS
FROM
PLACE OF
SERVICE
PROCEDURE/ANCILLARY/
ACCOMODATION CODE
MODIFIER
THRU
TOOTH
NUMBER
SURFACE
AMOUNT
BILLED
AMOUNT
PAID
TOTAL
Explanation/Comments: (retro review please submit supporting medical documentation)
Contact Name
Date
Phone Number
M6
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