Medical Fee Dispute Resolution Request and Worksheet Forms
| Form Name | Medical Fee Dispute Resolution Request and Worksheet |
| Form # | 440-2842a |
| Form Revision | 12/15 |
| Category | Forms » Medical/Health |
| Downloads | |
| Form State | Oregon |
| Language | English |
| State Description | Attachment to Form 440-2842; use when submitting a medical fee dispute. |
| Claimwire Description | n/a |