Get Part I General Information Requestor's Name And Address Waco Ortho Rehab Associates P - Tdi Texas

Filling out the PART I GENERAL INFORMATION form for medical fee dispute resolution is essential for ensuring your claims are properly represented. This guide provides clear, step-by-step instructions to help you complete this form accurately and effectively online.

Follow the steps to fill out the form with ease.

1. Click the ‘Get Form’ button to access the form and open it in your browser.
2. Enter the requestor's name: Write 'Waco Ortho Rehab Associates' in the designated field.
3. Provide the requestor's address: Fill in 'P.O. Box 2850' followed by 'Bryan, TX 77805-2850' in the address section.
4. Fill in the MFDR tracking number: You will see a field labeled for 'MFDR Tracking #'. Here, enter 'M4-05-1587-01'.
5. If applicable, enter the DWC claim number: Fill in this field if you have a DWC claim number specific to this case.
6. Specify the injured employee: If required, enter the name of the injured employee related to this case.
7. Identify the respondent name and box number: Below the requestor’s section, locate the corresponding field for 'Respondent Name and Box #' and fill in 'American Home Assurance Co.' and 'Box #: 19'.
8. Fill out the employer name: In the designated section for employer, provide the legal name of the employer associated with the case.
9. Enter the insurance carrier number: If you have this information, input the insurance carrier number in the appropriate field.
10. Complete additional required fields: Review the document for any other fields that may require information to ensure accurate submission.
11. After filling out all required fields, you can save your changes, download, print, or share the form as needed.

Start filling out the PART I GENERAL INFORMATION form online now to ensure your medical fee dispute is addressed promptly.