Provider And Insurer Application Form - Nys Independent Dispute Resolution For Emergency Services And Surprise Bills

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PROVIDER AND INSURER APPLICATION
NEW YORK STATE INDEPENDENT DISPUTE RESOLUTION FOR EMERGENCY SERVICES
AND SURPRISE BILLS
A provider or HMO/insurer (health plan) may dispute a payment or charge for emergency services or a
surprise bill. Applicants must: (1) visit the Department of Financial Services (DFS) website at
to receive a file number; (2) complete this application; and (3) send it to the assigned
independent dispute resolution entity. For help call 1-800-342-3736 or e-mail IDRquestions@dfs.ny.gov.
TO BE COMPLETED BY ALL APPLICANTS
1. File Number assigned by the DFS website: _____________________________________________
2. Applicant Name:____________________________________________________________________
[ ] Provider
[ ] Health plan (Please check one.)
3. Patient Name: ______________________________________________________________________
4. Patient Address: ____________________________________________________________________
__________________________________________________________________________________
5. Patient’s Health Plan ID Number: ______________________________________________________
6. Health Plan: _______________________________________________________________________
7. Health Plan Address: ________________________________________________________________
8. Phone Number: (_____)_______________________Fax Number: (_____)______________________
9. Provider Name: _____________________________________________________________________
10. Provider Address: __________________________________________________________________
11. Phone Number: (______)____________________Fax Number: (______)_______________________
12. Email Address: _____________________________________________________________________
13. What type of payment or charge are you disputing? (Please check one.)
[ ] Emergency Services
[ ] Surprise Bill for Other than Emergency Services
14. Date(s) of Service: __________________________________________________________________
15. Place of Service: ___________________________________________________________________
16. The fee charged by the provider (and include a copy of the bill): ____________________________
17. The fee paid to the provider: __________________________________________________________
18. The circumstances and complexity of the service including time and place, or submit when
contacted by the IDRE if you want considered: __________________________________________
__________________________________________________________________________________
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