This Arbitration Initiation Request Form (“AIRF”) is required by our office for any party initiating arbitration under the Balance Billing Protection Act. This mandatory form for parties to use is referred to as “Appendix A” in WAC 284-43B-035(1)(a) and WAC 284-43B-085. Submission of this form satisfies the notification requirements under RCW 48.49.040(3).

I understand OIC’s review is limited to determining whether the arbitration request has been timely submitted and is complete. Parties may challenge whether claims are subject to RCW 48.49 during arbitration.

View form instructions prior to filling out this form

  • Verification
  • Date check
  • Filing information
  • Initiating party
  • Non-initiating party
  • Description of health care services provided
  • Health care services provider information
  • Complete
Indicates required field

Verification

By signing and dating this form, you verify that the following information is true and correct.

  • The patient’s plan is regulated by the OIC or is a self-funded group health plan that has elected to participate in the BBPA
  • If this is a request for multiple claims, I have checked that all the claims involve the same carrier and provider/facility, all claims involve the same procedural code, or comparable code under a different procedural system, and all claims occurred within the same 30 business day period.
  • I have read the form instructions prior to filling out this form.
  • I agree I will send the confirmation email I receive to the non-initiating party within 24 hours of submitting this form using the verified address provided.