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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). An electronic PDF (WKC-9380-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-9380-E (Electronic Version - Word/87 KB)

WKC-9380-E (Electronic Version - pdf/91 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.