Document Number: WKC-9351-E
Description: To be completed by a database company to obtain certification for a health service fee database used for resolving reasonableness of fee disputes.
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-9351) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-9351-E (Electronic Version - Word/131 KB)
WKC-9351 (Print Version - pdf/30 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.