Get Application For Mediation Or Hearing Form B

This guide provides clear and detailed instructions on how to fill out the Application For Mediation Or Hearing Form B online. Following these steps will help ensure that your application is completed accurately and submitted without delays.

Follow the steps to fill out the form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employee identification information. Fill in the employee's name, social security number, date of birth, and address including city, state, ZIP code, and county of injury.
3. Next, provide the employer identification details. Enter the employer's name, federal I.D. number, and address including city, state, and ZIP code, along with the contact person's name and telephone number.
4. In the carrier identification section, input the name of the carrier or self-insured entity, NAIC or self-insured number, and their address details. Additionally, include the claim handler’s information and claim number.
5. Proceed to the health care provider identification section by filling the provider's name, license/registration/certification number, and address details including city, state, and ZIP code.
6. Specify the date of service and any billing information necessary. Input the amounts for the first and second billings and note any late fees requested.
7. Indicate the reason for filing. Refer to the provided reason codes and ensure the selection aligns with your situation.
8. If applicable, check the box indicating if the worker is currently denied treatment. Provide a detailed description of the needed treatment on the back of the form.
9. Securely add your signature by confirming the applicant's name, telephone number, email address, and date. If an attorney is involved, include their details as well.
10. Once all sections are completed, review the form for accuracy and completeness. Save your changes and download or print the form for submission.

Begin your application process now by filling out the form online.