Medical Care Provider Application Response Form


 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether a Medical Provider Application

  • is or will be accepted and paid;
  • is under review for repricing, negotiation, or other reason; or
  • is denied and for what reason; and
  • whether the employer, insurer, or claims administrator consents to issue mediation with the medical provider to try and resolve the claim together, with the help of a mediator, without the need for a hearing.



This form may be filed with the Commission in the following ways:

  • ONLINE: WebFile users may upload this form through their account. Click here to learn more about WebFile.
  • FAX: Fax the complete form to 804-823-6904
  • MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219
  • IN PERSON: Bring the completed form to any of our VWC Office Locations.

For questions please contact the Commission toll-free at 1-877-664-2566 or by email at