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
WKC-9498-E (Electronic Version - Word/119 KB)
WKC-9498-E (Electronic Version - pdf/32 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.