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MEDICAL FEE DISPUTE RESOLUTION FINDINGS AND DECISION GENERAL INFORMATION Requestor Name FONDLED ORTHOPEDIC GP, Correspondent Name LIBERTY MUTUAL INSURANCE COMDR Tracking Number M417256801Carriers

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How to fill out medical and facility fee

01

Obtain the medical and facility fee form from the healthcare provider or facility.

02

Fill in your personal information such as name, date of birth, and address.

03

Provide details of the medical services received, including the date of service and the name of the healthcare provider.

04

Calculate the total cost of services and enter it on the form.

05

Sign and date the form before submitting it to the healthcare provider or facility.

Who needs medical and facility fee?

01

Anyone who has received medical services from a healthcare provider or facility may need to fill out a medical and facility fee form to document the cost of services received.

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What is medical and facility fee?

Medical and facility fee is a fee charged for medical services and use of facilities in a healthcare setting.

Who is required to file medical and facility fee?

Healthcare providers and facilities are required to file medical and facility fee.

How to fill out medical and facility fee?

Medical and facility fee can be filled out by providing details of medical services provided and facility usage.

What is the purpose of medical and facility fee?

The purpose of medical and facility fee is to cover the cost of medical services and facility maintenance in a healthcare setting.

What information must be reported on medical and facility fee?

Information such as type of medical service, date of service, facility used, and cost must be reported on medical and facility fee.

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