Florida Regulations 59A-31.003

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§ 59A-31.003 Petition Form.

(1) The Petition for Resolution of Reimbursement Dispute Form (AHCA Form 3160-0023, effective September 8, 2006) is hereby incorporated by reference. This form may be obtained on the Internet at http://www.fldfs.com/wc/forms.html or by contacting the Agency at (850)413-1613.

(2) A petition to contest carrier disallowance or adjustment of payment pursuant to Section 440.13(7)(a), F.S., must be on the Petition for Resolution of Reimbursement Dispute Form. Any submission seeking to contest the disallowance or adjustment of payment by a carrier pursuant to Section 440.13(7)(a), F.S., must include a completed Petition for Resolution of Reimbursement Dispute Form.

Specific Authority 440.13(7)(e) FS. Law Implemented 440.13(7)(a) FS. History: New 11-28-06.