Disputed Claim for Medical Treatment Form to be filed with the Workers' Compensation Medical Service 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the last four digits of your Social Security Number, followed by the Date of Injury/Illness and Parts of Body Injured. This information is crucial for identifying your claim.
3. Fill in your Date of Birth and the Date of This Request. Ensure these dates are accurate to avoid processing delays.
4. Input your Claim Number, which is essential for tracking your dispute.
5. Indicate who is submitting the request by selecting Employee/Employee Attorney, Health Care Provider, or Other.
6. Complete the sections for Employee details, including Name, Address, Phone number, and if applicable, details for Employee’s Attorney and Employer.
7. Provide a summary of the details regarding the issue at dispute. You may attach additional documentation if necessary.
8. Finally, sign and date the form to certify that all information provided is true and correct before submitting it through our platform.

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