This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether a Medical Provider Application
- is or will be accepted and paid;
- is under review for repricing, negotiation, or other reason; or
- is denied and for what reason; and
- whether the employer, insurer, or claims administrator consents to issue mediation with the medical provider to try and resolve the claim together, with the help of a mediator, without the need for a hearing.
This form may be filed with the Commission in the following ways:
- ONLINE: WebFile users may upload this form through their account. Click here to learn more about WebFile.
- FAX: Fax the complete form to 804-823-6904
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219
- IN PERSON: Bring the completed form to any of our VWC Office Locations.
For questions please contact the Commission toll-free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.