Disputed Claim For Medical Treatment - Form 1009 Page 2
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PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE:
You may attach a letter or petition with additional information with this disputed claim.
By signing below, you are certifying that this form along with all supporting documentation has been sent to the carrier/self-
insured employer this date by e-mail or fax.
The information given above is true and correct to the best of my knowledge and belief.
SIGNATURE OF REQUESTING PARTY (Required)
DATE
Printed Named of Requesting Party
LWC-WC 1009-Rev 12/2014
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Parent category: Legal