Motion For Approval Of Disputed Charge
Download a blank fillable Motion For Approval Of Disputed Charge in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Motion For Approval Of Disputed Charge with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3________________________________
Name of party Submitting
_________________________________
Address of party Submitting
_________________________________
Phone of party Submitting
BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO
___________________
)
Provider,
)
MOTION FOR APPROVAL
)
OF DISPUTED CHARGE
v.
)
)
PATIENT:
___________________
)
Payor.
DATE(S) OF SERVICE:
)
DISPUTED AMOUNT: $
_________________________)
Comes now ___________________________, Provider, pursuant to Rule 19, JRP, and requests
the Industrial Commission of the State of Idaho for an order approving the fees for health care services
set forth in Appendix "A" attached hereto, which fees have been disputed. Payor has twenty-one (21)
calendar days from the date it receives this request to file its response. Rule 19, JRP.
Documents submitted in support of this motion are attached hereto and include the following:
1.
Appendix A (List of Disputed Charges)
2.
3.
4.
5.
DATED this ________ day of ________________, 20____.
________________________________
Provider or Agent
________________________________
Print or Type Name
Page 1 of 2 Appendix 6A
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal