Better Workers Compensation Built with you in mind. ADR Appeal to The MCO Medical Treatment/Service Decision Instructions: THE INJURED WORKER, EMPLOYER, AUTHORIZED REPRESENTATIVES OR PROVIDER MUST FILE THIS APPEAL WITH THE INJURED W S MCO.ORKERPlease print or type. Use this form to appeal the MCO medical treatment/service decision and to start the Alternative Dispute Resolution (ADR) process.Appeal to Level 1 must be filed within 14 days of receipt of the written notice of the MCO initial medical treatment/service decision.Appeal to Level 2 must be filed with the MCO within 7 days of the receipt of written notice of the MCO Level 1 decision.Complete this form to the best of your knowledge. THE INJURED WORKER NAME AND BWC CLAIM NUMBER ARE MANDATORY. INJURED WORKER NAME BWC CLAIM NUMBER APPEALED BY: (check appropriate box) Injured worker name Telephone number ( ) Injured worker representative name Representative I.D. number Telephone number ( ) Employer name Contact person Telephone number ( ) Employer representative name Representative I.D. number Telephone number ( ) Provider name Specialty Telephone number ( ) Level 1 APPEAL TO MCO Check if this is to appeal the initial MCO treatment/service decision. Date of MCO initial decision letter ____________________ Date of receipt of MCO initial decision _________________ Level 2 APPEAL TO BWC Check if this is to appeal the MCO Level 1 decision and refer the dispute to the Bureau of Workers Compensation. Date of MCO Level 1 decision _______________ Date of receipt of written notice ___________________ Was this treatment/service decision Denied Approved Amended Specify medical treatment/service you wish to appeal. Enter start date of Enter total number requested treatment of treatments __________ per week for _______ weeks OR per month for _______ monthsGIVE REASON FOR THE APPEAL. Please be specific, include any relevant information, any new evidence that will assist in apprl oovf ya our appeal.(Attach additional documentation if necessary.) Signature of party filing appeal Date BWC-1115 (Rev. 2/11/02) C-11 American LegalNet, Inc. www.USCourtForms.com