*** This page is being revised. Below are the forms for medical fee disputes. ***

The following forms are in Portable Document Format and require Adobe Acrobat Reader (version 7 or above recommended) to view, print and save. Click the button below for a free download of the most current version of the Adobe Acrobat Reader.

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• Application for Direct Payment (WC-MD-01)
• Application for Direct Payment (WC-MD-01) (*) Word 97/2000 Document
• Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-02)
• Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-02) (*) Word 97/2000 Document
• Application for Evidentiary Hearing (WC-MD-03)
• Application for Evidentiary Hearing (WC-MD-03) (*) Word 97/2000 Document
• Request for Dismissal of Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-05)
• Request for Dismissal of Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-05) (*) Word 97/2000 Document
• Request for Dismissal of Application for Direct Payment (WC-MD-10)
• Request for Dismissal of Application for Direct Payment (WC-MD-10) (*) Word 97/2000 Document
• Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194)
• Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194) (*) Word 97/2000 Document
• Answer to Application for Payment of Additional Reimbursement of Medical Fees (WC-198)
• Answer to Application for Payment of Additional Reimbursement of Medical Fees (WC-198) (*) Word 97/2000 Document
• Answer to Application for Direct Payment (WC-199)
• Answer to Application for Direct Payment (WC-199) (*) Word 97/2000 Document
• Entry of Appearance (WC-200)
• Entry of Appearance (WC-200) (*) Word 97/2000 Document
• Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-201)
• Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-201) (*) Word 97/2000 Document
• Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-202)
• Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-202) (*) Word 97/2000 Document
• Application for Administrative Ruling (WC-214)
• Application for Administrative Ruling (WC-214) (*) Word 97/2000 Document