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). If you do not have Microsoft Word we are providing a PDF (WKC-9498) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-9498-E (Electronic Version - Word/101 KB)
WKC-9498 (Print Version - pdf/254 KB)
*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.
*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page. Links to each specific vendor's site have been provided for you. Thank you.