Fill and Sign the Ky Dispute Form

Form 112 Filed: October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Medical Dispute Claim No. Before: vs. Plaintiff/Employee Defendant/Employee (business name) Social Security Number/Green Card Defendant Mailing Address Birth Date City/State/Postal Code Plaintiff/Employee Mailing Address Insurance Carrier City/State/Postal Code Carrier Mailing Address Country City/State/Postal Code Occupation * Date of injury / last exposure: * Cause of Injury: * Nature of Injury: * Body Part affected: Medical Provider Medical Provider Name Name Mailing Address Mailing Address City/State/Postal Code City/State/Postal Code Medical Provider Medical Provider Name Name Mailing Address Mailing Address City/State/Postal Code City/State/Postal Code * Comes and requests resolution of a medical dispute, and states as follows. This party is the: ☐ Employee ☐ Insurance Carrier ☐ Employer ☐ Medical Provider * Has a workers’ compensation claim been filed with the Department of Workers’ Claims? ☐ Yes ☐ No If yes, please provide claim number *A utilization review has been completed. ☐ Yes ☐ No If no, please explain why a utilization review is not required by 803 KAR 25:190 in this claim: NOTE: If utilization review is required by 803 KAR 25:190, no Medical Dispute may be filed prior to exhaustion of that process. The date(s) on which each disputed statement for services was first received by the employer, insurance carrier, or any agent thereof is as follows: Description Date First Received NOTE: A copy of all disputed statements for services must be attached hereto, including all required documentation. * 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.) * Has an award or settlement previously been entered on this claim? ☐ Yes ☐ No If yes, date of award or settlement: The following supporting documents are attached: ☐ Copy of the final utilization review decision ☐ Physician opinion supporting utilization review decision ☐ Medical bill audit, if any ☐ Copies of disputed statements for services ☐ Supporting medical documentation For reopening a claim to contest this medical treatment, the following additional items are attached: ☐ Motion to Reopen ☐ Affidavit(s) ☐ Medical Report ☐ Current medical release Form 106 signed and witnessed ☐ A copy of the Opinion and Award, Settlement, Agreed Order or Agreed Resolution sought to be reopened Submitting Party: *Name Role *Mailing Address Phone Number *City/State/Postal Code Email Address This information is true and accurate according to my knowledge and belief. Signature A copy of this filing has been sent to the following recipients: