The forms below are relevant to medical providers.
Click here to view documents for medical providers.

Request for Issue Mediation

 This form may be used by injured workers, deceased worker claimants, medical provider claimants, employers, insurers, claim administrators, and legal counsel to request Issue Mediation by a Commission mediator as a means of resolving a claims dispute. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.

Amputation Chart

The treating physician completes this form to provide information to support an injured worker’s claim which resulted in amputation to the foot, toes or metatarsal bones and/or hand, fingers or metacarpal bones.

The physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable. This will allow the Commission to determine an accurate entitlement of permanent partial disability benefits.

Medical Fee Schedule Dispute Response Form

Payment for services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a MFS Dispute Request Form along with supporting documentation to the Medical Fee Services Department for administrative review and determination.

Medical Fee Schedule Dispute Request Form

Payment for services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a MFS Dispute Request Form along with supporting documentation to the Medical Fee Services Department for administrative review and determination.

Change In Condition Claims Response Form

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether an injured worker’s Change in Condition Claim.

  • is accepted, accepted in part and denied in part, or denied;
  • the reasons for acceptance or denial, and, if denied in whole or in part;
  • whether the employer, insurer, or claims administrator consents to issue mediation with the injured worker to try and resolve the claim together, with the help of a mediator, without the need for a hearing.