Response To Request For Payment Of Charges For Health {MFDR Form 10M}

MFDR FORM 10M - RESPONSE TO PROVIDER REQUEST FOR MEDICAL FEE DISPUTE RESOLUTION. This form is used in Oklahoma workers' compensation cases to respond to a provider's request for medical fee dispute resolution. It allows the respondent (typically the employer, insurance carrier, or their counsel) to explain the reasons for refusing payment for medical treatment or services rendered to a claimant. The form addresses issues like the necessity of the treatment, whether it was provided by an unauthorized physician, or the denial of compensability for the claimant's injury. It also includes space for the respondent to present their position on the dispute, list potential witnesses, and identify relevant exhibits. The form must be submitted to the Workers' Compensation Commission, the claimant or their attorney, and the provider involved. www.FormsWorkflow.com