Free Motion for Reconsideration - 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 FOR RECONSIDERATION PROVIDER, v. PATIENT: SOC. SEC. NO: DATE(S) OF SERVICE: DISPUTED AMOUNT: $ DISPUTE NO.: ____________________

PAYOR.

COMES NOW ____________________________, Movant, pursuant to Judicial Rule (B)(3)(a) as referenced in IDAPA 17002.08.032 and requests that the Industrial Commission of the State of Idaho review the Administrative Order on Motion for Approval of Disputed Charge filed in this matter. This Motion is based on the Administrative Order, pleadings and exhibits filed with the Commission in this matter, and on other information relied on by Commission staff. If filed herewith, this Motion is also based on the Motion to Present Additional Evidence and on the information and evidence filed in support of the Motion. Movant requests that the Industrial Commission review the Administrative Order for the following reasons: 1. __________________________________________________________________________ __________________________________________________________________________

MOTION FOR RECONSIDERATION - 1

2.

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I certify that the information herein is true and accurate to the best of my information and belief. DATED This Day of __________________, 20__.

BY: Signature of Authorized Agent

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

copy of this Administrative Order 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 FOR RECONSIDERATION - 2

MOTION FOR RECONSIDERATION - 3