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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 template that can be filled out on your computer using Microsoft Word or Adobe Acrobat.
Content Contact: Lynn Weinberger
Document Attachments:
WKC-9498-E (Electronic Version - Word/33 KB)
WKC-9498-E (Electronic Version - pdf/244 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
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