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INTERNAL DISPUTE RESOLUTION REQUEST FORM Date: ________________________ Claim Number: __________________ Policyholder Name: _________________________________ Date of Loss: ____________________ Claim representative: ________________________________ Provider Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Telephone: ______________________________ Fax: _______________________________________________ Provider Attorney (if applicable) Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Telephone: ______________________________ Fax: _______________________________________________ Injured Party Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Telephone: ______________________________ Fax: _______________________________________________ Injured party Attorney (If known: name, address, phone): ______________________________________________ _____________________________________________________________________________________________ Injury Information Brief description of the injuries: ___________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Nature of dispute: ______________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please select a reviewer from the enclosed panel of physicians. For a current list, please select a name from the panel provided at http://www.medlogix.com or contact State Farm. Name: ___________________________________________________________________________________ Have you executed a State Farm Conditional Assignment of Benefits? (If yes, please attach copy of Assignment of Benefits) No Yes Dispute Type (Check all that apply): Medical Necessity of treatment/testing/services Relationship of injury/treatment/testing/services to Motor Vehicle Accident Date(s) of Service Date Bill Submitted to State Farm Amount in Dispute Filing Instructions Please send an original and one (1) copy of this Internal Dispute Resolution Request Form with copies of supporting information to: State Farm PO Box 696044 San Antonio, TX 78269-6044 OR Fax: (866) 497-2745 Signature: ____________________________________________________________________ Date: ______________ A copy of the independent reviewer’s determination will be sent directly to you. The Internal Dispute Resolution process is non-binding. The decision may be rejected in writing by either party. If you have a properly executed State Farm Conditional Assignment of Benefits, you may be required to complete this process prior to accessing PIP Dispute Resolution in accordance with State Farm automobile policy and as set forth in NJAC 11:3-5 and NJ Law.