Necessity of Treatment Dispute Resolution Request
Document Number: WKC-9380-E
Description: This form is to request an independent review.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we are providing a PDF (WKC-9380) which you can print and complete by hand.
Content Contact: Kathy Froehlich
WKC-9380-E (Electronic Version - Word/92 KB)
WKC-9380 (Print Version - pdf/118 KB)
*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.
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