Reasonableness of Fee Dispute Resolution Request

Document Number:  WKC-9498

Description:  This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992.

Comments:  This form is not fill-enabled. It can be printed and completed by hand.

Content Contact:  Kathy Froehlich

Document Attachment:  WKC-9498 (pdf/18 KB)

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