ATTENTION: The Workers’ Compensation Commission will NOT set this MFDR Form 19 for hearing unless it is attached to a CC-Form-9, “Request for Hearing”.

Send a copy of the CC-Form-9, MFDR Form 19 and the following to the workers’ compensation PAYOR:

(1) a paper copy of all medical bills related to the dispute, as originally submitted to the payor;

(2) a paper copy of each explanation of benefits (EOB) related to the dispute as originally submitted to the health care provider;

(3) a copy of all applicable medical records related to the date(s) of service in the dispute; and

(4) any other documentation that the provider deems applicable to the medical fee dispute.

DO NOT ATTACH ANY SUCH RECORDS OR DOCUMENTATION TO THE MFDR FORM 19 WHEN THE FORM IS FILED WITH THE COMMISSION.

For assistance and general information about completing and submitting this form, contact the Workers’ Compensation Commission’s Counselor Division, (405) 522-5308 or In-State Toll Free (855) 291-3612

Links to Forms 

MFDR Form 19

CC-Form-9