Ne: (608) 264-6819 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Direct all inquiries to: Medical Cost Dispute Unit and mail to the address above or telephone (608) 264-6819. INSTRUCTIONS: Complete Section 1 or Section 2 and all sections (3, 4 & 5) on the reverse side. You are the RESPONDENT in this matter. Provision of the Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you.
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How to fill out the WI WKC-9380 online
Navigating the WI WKC-9380 form for a necessity of treatment dispute can seem challenging. This guide provides clear and supportive instructions to help you complete the form accurately and efficiently online.
Follow the steps to fill out the WI WKC-9380 form online effectively.
- Press the ‘Get Form’ button to access the WI WKC-9380 form and open it in the editor for online completion.
- Identify whether you will complete Section 1 for independent review or Section 2 for default order. Only one of these sections should be filled out.
- In Section 1, enter the date you received notice of the insurer or self-insurer’s denial of payment. Clearly detail the reasons provided by the insurer regarding the necessity of your treatment.
- Complete Sections 3, 4, and 5 on the reverse side. In Section 3, provide your name, address, and details of the insurer or self-insurer.
- In Section 4, list the specific treatments in dispute, including dates of treatment, amounts charged, and amounts paid. Ensure the totals are calculated accurately.
- In Section 5, confirm that you are enclosing all necessary documentation related to the dispute, including any correspondence from the insurer and your written response.
- Finally, review all provided information for accuracy. Once completed, you can save changes, download the form, print, or share it as needed.
Complete your WI WKC-9380 form online today for a smoother dispute resolution process.
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