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File Size: 78.8 kB
Pages: 2
Date: May 23, 2008
File Format: PDF
State: Minnesota
Category: Workers Compensation
Word Count: 866 Words, 5,454 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.mn.gov/WC/PDF/mq03.pdf

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Medical Request
CHECK BOX IF THIS REQUEST ADDS MEDICAL ISSUES TO A PENDING MEDICAL REQUEST WID or SSN
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.
M Q 0 3

NOTE: Before filing this form, call the workers' compensation insurer. If that does not resolve the issue, call Workers' Compensation Benefit Management and Resolution at (651) 284-5032 (or 1-800-342-5354).

DO NOT USE THIS SPACE

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: This form must be filled out completely; otherwise, it may be returned to you. The injured worker's name, WID or social security number, and date of injury must be written on all attached documents. This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee's Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer's Attorney

Health Care Provider

2. 3.

Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information showing that the dispute resolution process of the certified managed care plan has already been exhausted. MEDICAL ISSUES (check only those that apply) I request: a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets if needed. Itemized bills and supporting medical reports must be attached.) NAME ADDRESS UNPAID BALANCE

b. FROM: TO: c. d. e.

a change of treating doctor: NAME NAME ADDRESS ADDRESS SPECIALTY SPECIALTY

that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting medical reports.) that the employee's medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports. a second opinion or consultation with NAME SPECIALTY

f.

other (explain):

MN MQ03 (5/08)

(over)

IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST. 4. HAS ANYONE OTHER THAN THE WORKERS' COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO THIS DISPUTE? YES NO If yes, bills were paid by: Medicare NAME employee Veterans Administration Dept. of Human Services (Welfare) other POLICY NUMBER

Social Security Administration ADDRESS

private health insurance

In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.

5.

Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers' Compensation Division file, and the response to this form.

6.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys, and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #6 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers' Compensation Division Department of Labor and Industry PO Box 64218 St. Paul, MN 55164-0218
Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers' compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.