Application For Fee Review Pursuant To Section 306 (F.1) {LIBC-507}

002 002 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION APPLICATION FOR FEE REVIEW002 PURSUANT TO SECTION 306 (F.1)002 003 ----PATIENT/EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)Name Address Address City/Town State ZIP County TelephoneContact NAIC code or Insurer code PROVIDER Name Address Address City/Town State ZIP TelephoneFederal tax ID number MC Provider #NPI # Specialty Contact PROVIDER REPRESENTATIVE or CORRESPONDENCE ADDRESS (if Other than Above)Name Address Address City/Town State ZIP Telephone NOTICE: 003Address Address City/Town State ZIP County Telephone FEIN INSTRUCTIONS: American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 002 PROOF OF SERVICE --Insurer/Employer Street address City/Town State ZIP via (Typed/Printed)Telephone Paid No part/ response Denied from Paid Denied part insurer Dates of service submitted to carrier:002 From To002 ------ ------ ------ ------ *507*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com