Informal Payment Dispute Resolution Process
The Informal Payment Dispute Resolution Process is an informal process by the Medical Resource Office of the Industrial Commission of Arizona to assist stakeholders in discussing payment disputes. We cannot guarantee the participation of all parties involved, or that we can resolve every issue.
Instructions for Informal Payment Dispute Form
A healthcare provider, payer, injured worker, or their representative may complete an Informal Payment Dispute Form to request assistance from the Medical Resource Office.
IMPORTANT:
This form must be completed along with the submission of supporting documentation. Failure to do so may cause an inability to proceed or a delay in the Informal Payment Dispute request.