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Reasonableness of Fee Dispute Resolution Request

Document Number: WKC-9498-E

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

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-9498-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-9498-E (Electronic Version - Word/122 KB)

WKC-9498-E (Electronic Version - pdf/195 KB)

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