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Independent Dispute Resolution - Uninsured Form

All fields with * after them are required fields. You cannot submit your report until all required fields are completed.

Your Information

Prefix

First *

Middle

Last *

Telephone Primary *

Telephone Secondary

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Medical Service Provider Information

Prefix

First *

Middle

Last *

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Telephone

Service Information

Date of Service

Type of Service Provided *

Was the total bill for this service greater than $750?

Yes

Please provide a copy of the bill to Insurance.PFR@maine.gov or send a fax to (207)-624-8599.

The dollar figure you will accept as the amount for the dispute:

Any other information you believe relevant:

Attestation:

I hereby agree to be bound by the outcome of the IDR, to submit to the jurisdiction of the Superintendent, and the courts of this State in this matter. I also affirm that the information provided in this application is true and accurate to the best of my knowledge.

Completed By *

Email *

Date *

Maine.gov

Independent Dispute Resolution - Uninsured Form