Form A "Petition for Non-network Providers of Emergency Care Services Health Care Reimbursement for Emergency Care Arbitration" - Delaware

What Is Form A?

This is a legal form that was released by the Delaware Department of Insurance - a government authority operating within Delaware. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Delaware Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form A by clicking the link below or browse more documents and templates provided by the Delaware Department of Insurance.

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Download Form A "Petition for Non-network Providers of Emergency Care Services Health Care Reimbursement for Emergency Care Arbitration" - Delaware

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Regulation 1316 – Form A
Petition for Non-Network Providers of Emergency Care Services Health Care Reimbursement for
Emergency Care Arbitration
Arbitration Case # _______________
(Office use only)
Claimant Name
Claimant Practice Group
Claimant Address
Work Phone #
Name of insurance company against which you are making a claim
Insurance company address
Insurance company phone #
Name of Policyholder
Policyholder Address
Policy #
Was the policyholder: _____ Patient _____ Spouse ______ Parent or guardian ____ Power of attorney ____ Other
Date of determination of denial of claim
Amount of your claim
$
Dates of Service
From:
To:
Briefly describe the basis for your claim. Be sure to include the
individual CPT Codes in dispute and attach the notification or
explanation of provider payment (EPP) that you received from the
insurance company (if needed, attach separate sheet).
Prior to the hearing, it is necessary that you submit the appropriate documents to support your Petition to the Delaware
Department of Insurance and to the opposing party.
Parties may present witnesses on their behalf at the hearing, provided that due notice is given. Please list the name, address, and
telephone number of all witnesses you expect to appear on your behalf on a separate sheet and attach it to this form.
If a settlement has been offered to you, how much was it? $___________________
Who will represent you at the hearing? _______ Self ________ Attorney
If an attorney will represent you, please provide the following:
Name: _________________________________ Address:
____________________________________________________________
Phone #: _______________________________
Under Delaware law, any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement
or claim containing false, incomplete, or misleading information is guilty of a felony.
___________________________________________________
__________________________________
Your Signature
Date
Note: In addition to submitting this form to the Department of Insurance, you must also send a copy of this Petition to the insurance
company by certified mail, return receipt requested. Use Form C to provide confirmation to the Department that a copy of this
Petition was sent to the insurance company. (Forms are available at www.delawareinsurance.gov.)
Filing Fee: There is a non-refundable filing fee of $75 for each claim. Please enclose a check made payable to the Delaware
Department of Insurance.
For the insurance company recipient: Within 20 days of receiving this
Arbitration Secretary
Petition, you must return a Form B Response to Petition and (1) copy
Delaware Department of Insurance
to:
1351 West North St., Suite 101 Dover, DE 19904
Regulation 1316 – Form A
Petition for Non-Network Providers of Emergency Care Services Health Care Reimbursement for
Emergency Care Arbitration
Arbitration Case # _______________
(Office use only)
Claimant Name
Claimant Practice Group
Claimant Address
Work Phone #
Name of insurance company against which you are making a claim
Insurance company address
Insurance company phone #
Name of Policyholder
Policyholder Address
Policy #
Was the policyholder: _____ Patient _____ Spouse ______ Parent or guardian ____ Power of attorney ____ Other
Date of determination of denial of claim
Amount of your claim
$
Dates of Service
From:
To:
Briefly describe the basis for your claim. Be sure to include the
individual CPT Codes in dispute and attach the notification or
explanation of provider payment (EPP) that you received from the
insurance company (if needed, attach separate sheet).
Prior to the hearing, it is necessary that you submit the appropriate documents to support your Petition to the Delaware
Department of Insurance and to the opposing party.
Parties may present witnesses on their behalf at the hearing, provided that due notice is given. Please list the name, address, and
telephone number of all witnesses you expect to appear on your behalf on a separate sheet and attach it to this form.
If a settlement has been offered to you, how much was it? $___________________
Who will represent you at the hearing? _______ Self ________ Attorney
If an attorney will represent you, please provide the following:
Name: _________________________________ Address:
____________________________________________________________
Phone #: _______________________________
Under Delaware law, any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement
or claim containing false, incomplete, or misleading information is guilty of a felony.
___________________________________________________
__________________________________
Your Signature
Date
Note: In addition to submitting this form to the Department of Insurance, you must also send a copy of this Petition to the insurance
company by certified mail, return receipt requested. Use Form C to provide confirmation to the Department that a copy of this
Petition was sent to the insurance company. (Forms are available at www.delawareinsurance.gov.)
Filing Fee: There is a non-refundable filing fee of $75 for each claim. Please enclose a check made payable to the Delaware
Department of Insurance.
For the insurance company recipient: Within 20 days of receiving this
Arbitration Secretary
Petition, you must return a Form B Response to Petition and (1) copy
Delaware Department of Insurance
to:
1351 West North St., Suite 101 Dover, DE 19904