Get Form024f.doc - Laborcommission Utah

Filling out the Form024f.doc is an important step for medical care providers seeking to request a hearing related to workplace injuries in Utah. This guide will walk you through each section of the form, ensuring that you provide the necessary information accurately and completely.

Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to access the document and open it in your editing tool.
2. Begin by filling out the top section with the medical care provider's name, as well as the name of the injured employee. Ensure this information is accurate to avoid processing delays.
3. In the next section, specify the respondent's information, including their name, mailing address, and phone number. It is vital to provide the correct details as this will help in communication about the claims.
4. Indicate whether you have the mailing address and phone number for the respondent’s insurance carrier. If you lack this information, refer to the Labor Commission’s resources to obtain it.
5. List the name and details of the respondent's worker’s compensation insurance carrier. This includes the mailing address and phone number.
6. Clearly state the date of the industrial injury using the provided fields to indicate the month, day, and year.
7. Provide detailed information about the medical charges that are in question. Remember to attach an itemized account of services rendered, including dates, specific charges, and billing codes.
8. Document any amounts already paid by the respondents to date, ensuring this reflects the accurate figures.
9. Describe the injuries sustained by the employee due to the accident, making sure to be thorough in your account.
10. If applicable, confirm that restorative services billing is noted, and include any relevant RSA forms.
11. In the verification section, include the printed name, signature, and contact information of the attorney for the petitioner. Ensure all fields are filled out completely.
12. Finally, secure the petitioner’s signature and complete their contact information, including mailing address, phone number, and email address.
13. After verifying that all information is correct, save your changes. You may choose to download, print, or share the completed form as required.

Complete your Form024f.doc online now to facilitate your request for a hearing with the Labor Commission.