Document Number: WKC-9498-E
Description: This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we are providing a PDF (WKC-9498) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-9498-E (Electronic Version - Word/119 KB)
WKC-9498 (Print Version - pdf/32 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.