Notice To Chair Of Withdrawal Of Request For Arbitration {HP-4}

HP-4 - NOTICE TO CHAIR WORKERS’ COMPENSATION BOARD WITHDRAWAL OF REQUEST FOR ARBITRATION. This form is used for notifying the Workers' Compensation Board in the State of New York about the withdrawal of a request for arbitration in a workers' compensation case. The form is to be completed by either the insurer or the health provider and includes information such as the type of care, dispute numbers, names and addresses of the health provider and carrier, claimant's details, date of accident, bills being withdrawn, and signatures of the health provider and insurer representative. The form provides instructions on where and how to file it with the Workers' Compensation Board's Medical Director's Office. www.FormsWorkflow.com