Send original to Workers' Compensation Court and 1 copy to: Insurance Carrier, Self-Insured Employer/Own Risk Group or Uninsured Employer In re claim of:
Full Name of Injured Employee (Claimant)
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLA.CITY, OKLAHOMA 73105-4918
THIS SPACE FOR COURT USE ONLY
Employee's Social Security Number
Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual SelfInsured or Own Risk Group, Uninsured
REQUEST FOR ADMINISTRATIVE REVIEW OF DISPUTED MEDICAL CHARGES FILE NO. Date of Injury
NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210. (Please Type or Print)
Address of employee Address of employer City City State State Zip Zip
Has any order determining compensability been entered?
Describe the treatment or services rendered.
Explain fully why this charge is being disputed, or why this charge should be allowed, referencing procedure codes and/or Ground Rules from the Schedule of Medical and Hospital Fees. This MUST be filled out in detail. If additional space is required, attach a separate sheet.
A COPY OF THE ACTUAL DISPUTED MEDICAL BILL MUST BE ATTACHED, TOGETHER WITH A COPY OF THE PAYOR'S EXPLANATION OF BENEFITS. The bill must include: 1. 2. 3. Dates of Service, listed chronologically, with procedure codes and charges for services rendered; Notation of all payments received; and Explanation of unusual services or circumstances.
I declare under penalty of perjury that I have examined this request, including all statements contained herein, and to the best of my knowledge and belief, it is true, correct and complete. Further, I hereby certify that a copy of this request for administrative review, including all supporting documentation, has been mailed to each interested party. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.
Signed this________________day of______________________,___________
I HEREBY CERTIFY THAT A COPY, TOGETHER WITH ATTACHMENTS, HAS BEEN SENT TO:
Self-Insured Employer/Own Risk Group Insurance Carrier
_________________________________________________________________________ Signature of Authorized Requesting Party Uninsured Employer
Name of Provider Address (Number & Street)
Address (Number & Street) City State Zip Code
City Telephone #
State Tax ID #