Free ADMINISTRATIVE ORDER OF DEFAULT - Idaho

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Name of party Submitting

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Address of party Submitting

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Phone of party Submitting

BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO MOTION TO PRESENT ADDITIONAL EVIDENCE PROVIDER, DISPUTE NO.: ____________________ v. PATIENT: SOC. SEC. NO: DATE(S) OF SERVICE: DISPUTED AMOUNT: $

PAYOR.

COMES NOW ____________________________, Movant, pursuant to Judicial Rule (B)(3)(b) as referenced in IDAPA 17002.08.032 and requests that the Industrial Commission of the State of Idaho receive further evidence in support of Movant's Motion for Reconsideration filed in this matter. 1. Movant requests leave to submit additional evidence is because ____________________ ___________________________________________________________________________ 2. Movant desires to present the following evidence: _______________________________ ___________________________________________________________________________ 3. The proposed evidence is relevant to the issue(s) before the Industrial Commission because ___________________________________________________________________________ ___________________________________________________________________________ MOTION TO PRESENT ADDITIONAL EVIDENCE - 1

4. The proposed evidence was not presented to the staff because ______________________ ___________________________________________________________________________ 5. Movant seeks to present this evidence by _______________________________________ ___________________________________________________________________________

I certify that the information herein is true and accurate to the best of my information and belief.

DATED This

Day of __________________, 1999.

BY: Signature of Authorized Agent

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

this Motion to Present Additional Evidence was served by upon each of the following, as noted: IDAHO INDUSTRIAL COMMISSION MEDICAL FEE DISPUTE COORDINATOR PO BOX 83720 BOISE, ID 83720-0041
Other Party's Address:

US Mail Hand Delivery Fax US Mail Hand Delivery Fax

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Signature of Authorized Agent

MOTION TO PRESENT ADDITIONAL EVIDENCE - 2