Motion For Approval Of Disputed Charge Page 2

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

CERTIFICATE OF SERVICE
I hereby certify that on the _____ day of _______________, 20____, a true and correct copy of
this Motion was served upon each of the following, as noted:
IDAHO INDUSTRIAL COMMISSION
US Mail
_______
MEDICAL FEE DISPUTE COORDINATOR
PO BOX 83720
Hand Delivery
_______
BOISE ID 83720-0041
Fax
_______
Payor's Address:
US Mail
_______
Hand Delivery
_______
Fax
_______
______________________________________
Provider or Agent Signature
_______________________________________
Print or Type Name
Page 2 of 2 – Appendix 6A

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3