The Wisconsin Reasonableness of Fee Dispute Resolution Request Form is intended for use by medical providers and patients to resolve disputes over the fees charged for treatments received on or after July 1, 1992. This form is designed to allow both parties to submit information and documentation regarding the dispute, and to provide a mechanism for resolving the dispute in a fair and equitable manner. The form requires the patient and provider to provide a detailed description of the services provided, the fee charged, and the fee that is being disputed. The form also includes a section for the patient to provide an explanation of why the fee is unreasonable. Once the form is completed, it must be submitted to the Wisconsin Department of Health Services for review and resolution. The Wisconsin Reasonableness of Fee Dispute Resolution Request Form is available online, and can be downloaded and printed for free.
Wisconsin Reasonableness of Fee Dispute Resolution Request Form -- This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992.
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How to fill out Wisconsin Reasonableness Of Fee Dispute Resolution Request Form -- This Form Should Be Used ONLY For Fee Disputes Related To Treatment Provided On Or After July 1, 1992.?
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