Form 024 2/08 State of Utah - Labor Commission Division of Adjudication 160 East 300 South, 3rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 laborcommission.utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK ____________________________________________ Medical care provider ___________________________________________ Injured Employee APPLICATION FOR HEARING MEDICAL CARE PROVIDER (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned) Vs. ____________________________________________ Respondent (Employer) ____________________________________________ Respondent’s mailing address I request to have a Claims Resolution Conference scheduled to resolve the issues checked below  YES  NO ____________________________________________ City, State and Zip Code ____________________________________________ Respondent’s phone number ____________________________________________ Respondent’s worker’s compensation insurance carrier PETITIONER ALLEGES AND REQUESTS RESOLUTION CONCERNING THE FOLLOWING UNDER TITLE 34A: 1. Date of industrial injury: Month _____ Date _____ Year______. 2. Medical charges at issue (you must attach an itemized, detailed account of the services rendered, the date of the services, the charges for the services, and the correct RBRVS billing code). 3. Amounts paid by respondents to date ___________________________________________ 4. The injuries employee sustained from the accident are: _______________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 5. If you are billing for restorative services you must include RSA forms. American LegalNet, Inc. www.FormsWorkflow.com Petitioner verifies that the above information is true and correct to the best of petitioner’s information and belief. ____________________________________________ Printed Name of Attorney for Petitioner State Bar # ________________________________________________ Signature of Petitioner Date ____________________________________________ Signature of Attorney for Petitioner ________________________________________________ Mailing Address of Petitioner ____________________________________________ Mailing Address for Attorney for Petitioner ________________________________________________ City/State/Zip Code ____________________________________________ City/State/Zip Code (____)__________________________________________ Petitioner’s Telephone Number ___(___)_____________________________________ Telephone Number ________________________________________________ Petitioner’s Social Security Number ___(___)_____________________________________ FAX E Mail Address If you know the name and address of the adjuster or third party administrator that you have dealt with concerning your claim please include that information: ____________________________________________________ Name of adjuster or third party administrator _____________________________________________________ Mailing address for adjuster or third party administrator _____________________________________________________ City/State/Zip Code American LegalNet, Inc. www.FormsWorkflow.com