FORM INTERROGATORIES - HEALTHCARE DISPUTE

Instructions

1. Answer each interrogatory separately and fully in writing under oath.
2. If you object, state the grounds and answer the non-objectionable portion.
3. Identify documents supporting each response.

Interrogatories

1. Identify all providers, facilities, or staff involved in the care at issue.
2. Describe the services rendered and dates of service.
3. Identify all billing codes and amounts charged.
4. Describe the basis for any disputed charges or denials.
5. Identify all communications regarding the disputed services or bills.
6. Identify applicable policies, procedures, or compliance standards.
7. Identify all insurance or payor coverage relevant to the dispute.
8. Describe any audit, review, or utilization management decisions.
9. Identify any damages claimed and how they were calculated.
10. Identify all documents supporting your position.

Verification

text
I declare under penalty of perjury that the foregoing answers are true and correct.

______________________________
[RESPONDING PARTY NAME]
Date: [DATE]