Get Part I General Information Requestor's Name And Address Summit Rehabilitaton Centers Co The Morris

Filling out the PART I GENERAL INFORMATION section of the Requestor's Name and Address form for SUMMIT REHABILITATON CENTERS CO THE MORRIS is a crucial step in the Medical Fee Dispute Resolution process. This guide will provide you with clear and supportive instructions to help you complete this section accurately and efficiently.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and display it on your screen.
2. Locate the field labeled 'Requestor's Name and Address'. Here, input the name 'SUMMIT REHABILITATON CENTERS' followed by the address details, which include 'C/O THE MORRIS LAW FIRM', '702 S BECKLEY AVE', 'DALLAS TX 75203'. Make sure that each section is filled out accurately to avoid issues with processing.
3. Next, find the 'MFDR Tracking #' field. Enter the tracking number 'M4-07-0239-01'. This number is important for tracking your case.
4. Proceed to the 'DWC Claim #' section, where you must enter the claim number relevant to the dispute.
5. In the 'Injured Employee' field, input the name of the person who was injured. This identifies the party involved in the dispute.
6. Next, provide the 'Date of Injury' in the designated area. This should be the exact date the injury occurred.
7. Find the section labeled 'Respondent Name and Box #.' Enter the name of the insurance company, which is 'American Home Assurance Co.' and the Box number 'Rep. Box # 19'.
8. Fill in the 'Employer Name' field with the name of the employer associated with the claim.
9. In the 'Insurance Carrier #' field, enter the specific insurance carrier number related to the case.
10. Once all fields are completed, save your changes. You may also choose to download, print, or share the form as needed.

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