Medical dispute




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Form 112 DEPARTMENT OF WORKERS’ CLAIMS

Medical Dispute 657 CHAMBERLIN AVENUE

Revised 9/3/02 FRANKFORT, KENTUCKY 40601

Claim No. _________________


MEDICAL DISPUTE

MOVANT RESPONDENT

________________________________ vs. ________________________________

Name Name

_______________________________________ _______________________________________

Street Address Street Address

_______________________________________ _______________________________________

City State Zip Code City State Zip Code

* * * * * * * * * * * * * * * * * * * * * *



Patient: Employer:

________________________________ _______________________________

Name Social Security Number Name

____________________________ __________ ____________________________

Street Address Date of Injury Street Address

­­­­­­­­­­­­­­­­­­­­­­­­­­­­

­­­­­­­­­­­­­­___________________________________________ _________________________________________

City State Zip Code City State Zip Code


Medical Payment Obligor: Counsel for Movant:
________________________________ ________________________________

Name Name

_______________________________ ________________________________

Street Address Street Address

________________________________ ________________________________

City State Zip Code City State Zip Code City. State, Zip Code



Medical Provider: Medical Provider:

________________________________ ________________________________ Name Name

________________________________ ________________________________

Street Address Street Address

________________________________ ________________________________

City State Zip Code City State Zip Code


Medical Provider: Medical Provider:

________________________________ ________________________________

Name Name

________________________________ ________________________________

Street Address Street Address

________________________________ ________________________________ City State Zip Code City State Zip Code City. State, Zip Code

* * * * * * * * * * * * * * * * * * * * *

Comes the movant and requests resolution of a medical dispute, and states as follows:

 A workers’ compensation claim has _____ has not ______ been filed with the Department of Workers’ Claims.

2. Utilization review and medical bill audit have been completed. A copy of the final utilization review decision with supporting physician opinions is attached. Yes__ No__



Note: If utilization review is required by 803 KAR 25:190, no Medical Dispute may be filed prior to exhaustion of that process.

 Utilization review is not required by 803 KAR 25:190 in this claim because (state specific reason): _____________________________________________________________

__________________________________________________________________________________________________________________________________________

 The date on which each disputed statement for services was first received by the payment obligor or any agent thereof is ____________________, 20______.
5. Copies of all disputed statements for services are attached hereto, including all required documentation. Yes ________ No __________
 The nature of this dispute can be briefly described as follows: (Please include all facts necessary for relief sought and attach copies of any supporting medical documentation.) __________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

This information is true and accurate according to my knowledge and belief.

_____________________________________

Movant's Signature

Subscribed and sworn to before me this _____ day of __________, 20______

Notary Public Signature

My Commission Expires: ___________________


Note: The respondent and all other parties have 20 days in which to file a response pursuant to 803 KAR 25:012. Copies of responses must be delivered to the Commissioner of the Department of Workers’ Claims and to all parties.
Certificate of Service

As required by 803 KAR 25:012, copies must be served on all parties, including the employee, employer, medical payment obligor, and the medical provider(s). I certify that true copies of this form and all attachments have been deposited in the United States mail today to the Commissioner of the Department of Workers’ Claims, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601, and to the following individuals or entities: (Please list names and addresses.)

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

4. _____________________________________________________________________

5. _____________________________________________________________________

6. _____________________________________________________________________


Date: ________________ ______________________________________________

Movant's Signature



NOTICE ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE

COMPANY OR OTHER PERSON FILES A STATEMENT OR CLAIM CONTAINING ANY

MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.


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