Arbitrator decision reporting form - Appendix B

Balance billing arbitrators will use this form to report their final decisions under "Appendix B".

This Arbitrator Decision Reporting Form is required by our office for arbitration proceedings under RCW 48.49.040.

Submission of this form satisfies the notification requirements under RCW 48.49.040(8)(a).

Note: Appendix B should not be used for arbitration decisions under RCW 48.49.135.

Indicates required field

Arbitrator's information

Date of decision

AIRF number

Arbitrator name

Street address

City

State

Zip code

Email address

Phone number

Dispute resolution information

Name of carrier

Name of health care provider that directly provided the service

Name of the health care provider’s group practice, employer or business entity in which provider has ownership interest

Street address

City

State

Zip code

Type of health care services at issue

Which parties’ final offer was chosen?