Form 26I is titled Medical Provider Dispute Resolution Questionnaire. This form is to be filled out by both the medical provider and the employer/insurance carrier. This form is what the medical provider fills out so they can be paid for the services provided in a worker’s compensation case. They must attach a list of services provided, a list of prices for each individual service and a total amount owed for all services together.

The medical provider should fill out Sections A through C and the employer/insurance carrier should fill out Section D. When the medical provider has filled out their part, they must furnish the form and list of services to the employer or their insurance carrier so that the rest of the form may be completed. The employer or insurance carrier must fill out Section D and provide the form back to the medical provider within 20 days of receipt of the form.

In Section D of Form 26I, the employer or their insurance carrier must disclose if they are denying the claim, admitting the claim or if they are not even the employer or insurance carrier for the claim. If they admit to the claim, they must state if they accept the liability for the list of services that was provided with the form from the medical provider. If they are denying the claim, they must state the reason why. They must also state if either party has requested a hearing before the Industrial Commission or if a settlement has been reached already.