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Date HP-1 Page 1 of 2 8-14 Osteopathic WCB Authorization Number Podiatry Health Provider s Signature SECTION A REQUEST FOR ADMINISTRATIVE AWARD - PLEASE COMPLETE THE FOLLOWING Federal Tax ID Number SSN Total Charge Amount Paid Amount in Dispute EIN Any arbitration involving 1 000 or less is handled by desk arbitration using a single arbitrator Desk. If you have any questions regarding the completion of this form you may contact us at 1-800-781-2362. A. The fee s billed is in accordance with ...

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