RDA 10183 Requesting Party: Employee Employee325s Atty. Employer/Carrier Employer325s/Carrier Atty. Employee325s Name State File # Employee325s Attorney325s Name Employer325s Name Adjuster325s Name Employer/Carrier Attorney325s Name Date Order issued Date Order received Date of Injury Name of WC Specialist What specific aspects of the Order issued by the WC Specialist do you disagree with, and why? Name of Opposing Party Email Teleconferences must be scheduled within ten calendar days of the receipt of this request unless waived by the parties. Please list your availability for the next ten days and provide the time zone for each time given. Contact name for scheduling: Email Name of Requesting Party Phone Company/Practice Name Business Address Phone Address 2 Fax City State ZIP Email By my signature below, I hereby certify that I have provided a true and completed copy of this form and all supporting documentation attached hereto to the opposing party and/or counsel for the opposing party. Signature Date LB-1016 (REV /1) American LegalNet, Inc. www.FormsWorkFlow.com