Free Form 112 - Kentucky

Form 112 Medical Dispute Revised 9/3/02

DEPARTMENT OF WORKERS' CLAIMS 657 CHAMBERLIN AVENUE FRANKFORT, KENTUCKY 40601 Claim No. _________________

MEDICAL DISPUTE
MOVANT RESPONDENT

________________________________
Name

vs. ________________________________
Name

_______________________________________
Street Address

_______________________________________
Street Address

_______________________________________
City State Zip Code

_______________________________________
City State Zip Code

Patient:

********************** Employer:

________________________________ ________________________________
Name Street Address City State Social Security Number Name

____________________________ __________
Date of Injury Zip Code

________________________________
State Zip Code

Street Address

________________________________
Medical Payment Obligor:

________________________________
City

Counsel for Movant:

________________________________ ________________________________
Name Name

________________________________
Street Address

________________________________
Street Address

________________________________ ________________________________
City State Zip Code

City

State

Zip Code

Medical Provider:

Medical Provider:
Name

________________________________ ________________________________
Name

________________________________ ________________________________
Street Address Street Address

________________________________ ________________________________
Medical Provider:

City

State

Zip Code

City

Medical Provider:

________________________________ ________________________________
Name Name

________________________________ ________________________________
Street Address Street Address

________________________________ ________________________________

City

State

Zip Code

City

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

1. 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. 3. Utilization review is not required by 803 KAR 25:190 in this claim because (state specific reason): ______________________________________________________ _____________________________________________________________________ _________ 4. 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 __________ 6. 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.