Provider'S Request For Second Bill Review (Dwc Form Sbr-1)
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State of California
Division of Workers’ Compensation
Provider’s Request for Second Bill Review
California Code of Regulations, title 8, section 9792.5.6
The Medical Provider signing below seeks reconsideration of the denial and/or adjustment
of the billed charges for the medical services or goods, or medical-legal services, provided to the injured employee.
Employee Information
Employee Name (Last, First, Middle):
Date of Birth (MM/DD/YYYY):
Claim Number:
Date of Injury (MM/DD/YYYY):
Employer Name:
Provider Information
Provider Name:
Contact Name:
Address:
Phone:
Fax Number:
E-mail Address:
NPI Number:
Claims Administrator Information
Claims Administrator Name:
Contact Name:
Address:
Phone:
Fax Number:
Bill Information
Provider’s or Claims Administrator’s Bill Identification Number (if any):
Date Explanation of Review Received by Provider:
List of disputed services or goods (attach additional pages if necessary):
Service/Good
Supporting
Date of
in Dispute
Service/Good
Amount
Amount
Amount in
Documentation
Service
(include modifier, if
Authorized?
Billed
Paid
Dispute
Attached?
any)
Yes
No
Yes
No
Reason for Requesting Second Bill Review and Description of Supporting Documentation:
Service/Good
Supporting
Date of
in Dispute
Service/Good
Amount
Amount
Amount in
Documentation
Service
(include modifier, if
Authorized?
Billed
Paid
Dispute
Attached?
any)
Yes
No
Yes
No
Reason for Requesting Second Bill Review and Description of Supporting Documentation:
Provider Signature:
Date:
DWC Form SBR-1 (Effective 2/2014)
Page 1
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