Self-Insurance Medical Provider Billing Dispute form
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
 Self-Insurance Medical Provider Billing Dispute form (170 KB DOC)
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| Description | A form for Providers to submit disputes to the department regarding payment of medical provider bills |
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| Detail | ||
| Form number | F207-207-000 | |
| Availability | Not available in print |
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| Keywords | bil, bill payment, bills, complain, complaint, dispute, interest, medical billing, medical bills, medical provider bills, non-payment, provider, underpayment | |
| Languages | English | |
| Valid dates | 12-2012 | |
| Contact information |
Self-Insurance
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| Web pages | ||
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