Medical Fee Dispute Resolution Worksheet Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Medical Fee Dispute Resolution Worksheet Form. This is a Oregon form and can be use in Request For Review Of Decision Or Resolution Of Dispute Workers Comp.
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Tags: Medical Fee Dispute Resolution Worksheet, 2330a, Oregon Workers Comp, Request For Review Of Decision Or Resolution Of Dispute
Workers’ Compensation Division
Medical Fee Dispute
Resolution Worksheet
Worker information
Worker name:
Phone:
Social Security No:
Claim No:
List specific codes and dates of services in dispute
Service dates
440-2330a (9/96/DCBS/WCD/WEB)
Code
Amount Billed
Attach copies of this sheet if more lines are needed
Amount Paid
2330a
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