DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION REQUEST FOR HEARING TO CONTEST FEE REVIEW002 DETERMINATION 002PATIENT/EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - PROVIDER Name Address Address City/Town State ZIP County Telephone FEIN Specialty Contact PATIENT/EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # EMPLOYER Name Address Address City/Town Telephone State FEIN ZIP THIS REQUEST IS BEING FILED BY: HEALTH CARE PROVIDER INSURER/EMPLOYER FEE REVIEW APPLICATION NUMBER(S) AND DATE OF FEE REVIEW DETERMINATIONS(S): Application number: Determination date: Application number: Determination date: TO THE FEE REVIEW HEARING OFFICE: BILLING FORM DATE OF BILL SERVICE DATE PROC/SVC CODE AMOUNT BILLED American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 002 002 002002 002 002 002 002 002 002 002 002 002 002 002002 002 002 factual Do Not attach supplemental pageslegal Do Not attach supplemental pagesRequesting Party or Representative222s signature PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney222s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone Requesting Party or Representative222s name (typed/printed) Telephone COUNSEL FOR RESPONDENT (if known):002 Attorney222s name002 PA Attorney ID number002 Firm name002 Address002 Address002 City/Town 002State ZIP002 Telephone002 N *606*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com