Updated WC-104C, Application for Mediation or Hearing

DATE:    February 20, 2017

TO:         All Interested Parties

FROM:   Mark C. Long, WCA Director
               Lisa Klaeren, Chief Magistrate


Please note that two additional “check box” options for users of Form WC-104C, Application for Mediation or Hearing have been added based on customer feedback.  With the addition of the options outlined below, the Workers’ Compensation Agency, in conjunction with the Board of Magistrates, hope to continue our efforts to streamline operations and procedures to better serve our customers.

The changes to Form WC-104C include new check boxes titled, “Petition to Determine Medical Treatment,” and “Redemption Only.”  Up until these additions, petitioners simply used the description section on the form to state their desire for a “redemption only” hearing.  Utilizing this check box will allow users to more easily indicate their intentions, and aid in processing.

Petitions received with the “Petition to Determine Medical Treatment,” box marked will be scheduled for a telephone mediation facilitated by Agency staff.  This informal dispute resolution forum will be utilized with the intent of providing the parties, including the carrier, the claimant, and the medical providers, with a less formal setting to discuss and resolve relevant issues. We believe that this new option is especially appropriate where issues have arisen surrounding reimbursement for opioid treatment per Rules 418.101008, 1008(a), and 1008(b).