COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Medical Fee : JUDICIAL SUBPOENA Plaintiff(s) Dispute Resolution Request : : Workers’ Compensation Division -against- Index No. Calendar No. Notice : When a dispute exists between a medical provider and an insurer, OAR 436-009-0008 allows an insurer, medical : provider, or injured worker to request an administrative review by the director of the Department of Consumer and Business Services to settle the dispute. A request for administrative review must be submitted to the director within 90 Defendant(s) : days of .the .date . . . aggrieved .party knew. or. should. have. known. that .the .dispute existed. As an alternative to . . . . . . the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . administrative review, your issue may be resolved by a less formal dispute-resolution process. This process allows the parties to work with a trained facilitator from the Medical Review Unit at an agreed-upon location to resolve the dispute. A medical reviewer may contact you about this process or, if you are interested in it, contact the Medical Review Unit at the phone number on OF THE of this form.NEW YORK THE PEOPLE the back STATE OF If you are aggrieved because of nonpayment or reduction of payment, you must do the following before submitting this form: TO 1. Contact the insurer to determine why payment has not been made or why payment has been reduced. Please submit documentation. GREETINGS: 2. Wait at least 45 days from the date the insurer received your billing. OAR 436-009-0030 WE COMMAND YOU, that all business and excuses being laid aside, you injured worker attend before In all cases of accepted compensable injury or illness under workers’ compensation law, theand each of youis not liable , the Honorable at the for payment for any services for the treatment of that injury or illness, except Court as provided in OAR 436-009-0015. located at County of in room , on day of , 20 , at o'clock in the noon, and at any recessed Worker information the or adjourned date, to testify and give evidence as a witness in this action on the part of the Worker name: Phone: Address: City, State, ZIP: Your failure to comply with this subpoena is punishable as a Claim no.: of court and will make you liable to contempt Social Security no.: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Date of injury: your failure to comply. result of Employer/insurer information Witness, Honorable Court in Employer name: County, , one of the Justices of the day of , 20 Employer’s workers’ compensation insurer: Insurer address: City, State, ZIP: (Attorney must sign above and type name below) Insurer phone: Provider information Attorney(s) for Medical provider name: Phone: Address: City, State, ZIP: Office and P.O. Address Contact person: Are you the attending physician (AP) or authorized nurse practitioner (NP)? If no, name of AP or NP: Address: 440-2330 (5/04/DCBS/WCD/WEB) Yes Phone: Telephone No.: Facsimile State, ZIP: City, No.: E-Mail Address: Mobile (continued on back) Tel. No.: No 2330 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. To be completed by requesting party : Calendar No. Directions: You must respond to the questions below. Please provide additional narrative information on a separate sheet, numbered to correspond to each item listed: : JUDICIAL SUBPOENA Plaintiff(s) Yes No -against: 1. Is the injured worker covered by an insurer/MCO contract? If yes, the MCO dispute-resolution process, if available, must be attempted prior to coming to the director; : documentation of that process and the resulting decision must be attached to this form. OAR 436-015-0110 : 2. Has the insurer paid a portion of the bill and/or notified you of the reasons for reduced payment? If no, please explain and include copies of documents describing actions you’ve taken to determine why billing Defendant(s) : . . . . . . . . . . was. .not . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . paid. If yes, attach the completed worksheet (Page 3 of this form) showing specific code(s) and dates of service in dispute. THE 3. Has the injured worker made payment for part or all of the services in dispute? PEOPLE OF THE STATE OF NEW YORK If Yes, attach a sheet listing dates of service, amounts billed, and amounts paid by the injured worker. TO 4. Have you billed any other insurance company for the dates of service in dispute? If yes, attach a sheet listing the insurance company, the dates of service, the amount billed, and the amount paid. 5. I have attached the following: GREETINGS: Statement identifying the grounds for questioning the disputed amount. Statement identifying the request for correction WE COMMAND YOU, that all business and and relief.being laid aside, you and each of you attend before excuses Documentation to support the request for review. (Documentation includes but is not limited to copies of original , the Honorable at the Court HCFA bills, chart notes, bill analysis from the insurer, operative reports, any correspondence between the parties located at County of regarding the dispute, copies of attending-physician treatment plan or palliative care treatment plan (if applicable), in room on the day of , 20 , dispute.) o'clock in the noon, and at any recessed and any, other documentation necessary to evaluate theat or adjourned date, to testify and give evidence as a witness in this action on the part of the Be aware that the decision regarding the appropriateness of the request may be limited to information received from the medical provider and the insurer. This form must Your failure to comply the medical provider or an authorized contempt of courtthe medical providerliable to be signed and dated by with this subpoena is punishable as a representative of and will make you or by the insurer/self-insured employer this subpoena was issued for a of the insurer/self-insured employer. Mailing instructionsa the party on whose behalf or an authorized representative maximum penalty of $50 and all damages sustained as are outlined below. failure to comply. result of your Certification statement Witness, Honorable , one of the Justices of the By signing below, I certify that: Court in County, day of , 20 1. I have answered all questions to the best of my ability. 2. Sufficient documentation to support the review request is attached. 3. The involved insurer or vendor (provider) has been provided a copy of the request for review and attached (Attorney must sign above and type name below) supporting documentation. 4. There is no issue of causation or compensability of the underlying claim or condition. Attorney(s) for Signature:________________________________________________________ Date:___________________________________ Send the completed, signed original of this form and all accompanying documents to: Workers’ Compensation Division Medical Review Unit Office and P.O. Address 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Telephone No.: Facsimile No.: For more information, please call the Medical Review Unit, (503) 947-7816 or (503) 947-7993 (TTY). E-Mail Address: 440-2330 (5/04/DCBS/WCD/WEB) Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com