Form 18 Request For Court Administrator Review Of Disputed Medical Charges

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FORM 18

COURT OF EXISTING CLAIMS

THIS SPACE FOR COURT USE ONLY

1915 NORTH STILES, STE 127

Send original to

OKLA.CITY, OKLAHOMA 73105-4918

Court of Existing Claims and 1 copy to:

Insurance Carrier, Self-Insured Employer/Own

Risk Group or Uninsured Employer

In re claim of:

Full Name of Injured Employee (Claimant)

Employee’s Social Security Number (LAST 4 DIGITS ONLY)

XXX-XX-___________________________

Name of Employer (Respondent)

REQUEST FOR COURT ADMINISTRATOR REVIEW OF DISPUTED MEDICAL CHARGES

Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-

WCC FILE NO.

Insured or Own Risk Group, Uninsured

Date of Injury

NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (918) 581-2714.

(Please Type or Print)

Address of employee

City

State

Zip

Address of employer

City

State

Zip

Has any order determining compensability been entered?

YES

Describe the treatment or services rendered.

Explain fully why this charge is being disputed, or why this charge should be allowed, referencing procedure codes and/or Ground Rules from the Schedule of Medical and Hospital

Fees. This MUST be filled out in detail. If additional space is required, attach a separate sheet.

A COPY OF THE ACTUAL DISPUTED MEDICAL BILL MUST BE ATTACHED, TOGETHER WITH A COPY OF THE PAYOR’S EXPLANATION OF

BENEFITS. The bill must include:

Dates of Service, listed chronologically, with procedure codes and charges for services rendered;

Notation of all payments received; and

Explanation of unusual services or circumstances.

I declare under penalty of perjury that I have examined this request, including all statements contained herein, and to the best of my knowledge

and belief, it is true, correct and complete. Further, I hereby certify that a copy of this request for administrative review, including all supporting

documentation, has been mailed to each interested party. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty

of a felony.

Signed this ________________day of_____________________________,___________

I HEREBY CERTIFY THAT A COPY, TOGETHER WITH

_________________________________________________________________________

ATTACHMENTS, HAS BEEN SENT TO:

Signature of Authorized Requesting Party



Name of Provider

Self-Insured Employer/Own Risk Group

Insurance Carrier

Uninsured Employer