Free ADMINISTRATIVE ORDER OF DEFAULT - Idaho

______________________________
Name of party Submitting

______________________________
Address of party Submitting

______________________________
Phone of party Submitting

BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO

PROVIDER, v.

RESPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE

PAYOR.

PATIENT: SOC. SEC. NO: DATE(S) OF SERVICE:

COMES NOW ____________________________, Payor, pursuant to Judicial Rule XIX, Judicial Rules of Practice and Procedure, and responds to the Motion for Approval of Disputed Charge filed by Payor in this matter. (Insert argument and discussion here. Payor should include any appropriate discussion. Payor should also submit any affidavits or documents in support of its response). DATED this _________ day of _______________________, 200__. ____________________________________ Signature of Authorized Agent

REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 1

CERTIFICATE OF SERVICE I hereby certify that on the Day of ____________ , ________, a true and correct

copy of this Motion for Approval of Disputed Charge was served by upon each of the following, as noted: IDAHO INDUSTRIAL COMMISSION MEDICAL FEE DISPUTE COORDINATOR PO BOX 83720 BOISE, ID 83720-0041 US Mail Hand Delivery Fax ________ ________ ________

Other Party's Address:

US Mail Hand Delivery Fax

________ ________ ________

Signature of Authorized Agent

REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 2

APPENDIX A MOTION FOR APPROVAL OF DISPUTED CHARGE Date of Service CPT Code / Item Description
(CPT Code is preferred)

Amount Billed

Amount Paid

Amount Objected to

REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 3

APPENDIX B AFFIDAVIT OF USUAL AND CUSTOMARY

I, ___________________________, hereby attest and certify that: 1. I have personal knowledge of the information stated in this Affidavit, and it is true and accurate to the best of my information and belief. 2. The charges listed in Appendix A arose from medical services for an industrial injury under the Idaho Workers' Compensation law. 3. The charges listed in Appendix A are this Provider's most frequent charge(s) for the item(s) listed. 4. These charges are the same for all patients, whether industrially injured or not. 5. Attached hereto, or set out below, is: (check one)

_____ an accurate copy of our standard fee schedule for the items in Appendix A, (or) _____ bills for other patients, non-industrially injured, for the same service/treatment/charge.

DATED This ______ day of ___________________, ___________.

___________________________________ Authorized Agent

REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 4