Free D-35 - Nevada

State of Nevada Department of Business and Industry DIVISION OF INDUSTRIAL RELATIONS
Workers' Compensation Section 1301 North Green Valley Pkwy., Suite 200 400 West King Street, Suite 400 Henderson, Nevada 89074 Carson City, Nevada 89703 (775) 684-7270 (775) 687-6305 FAX (702) 486-9080 (702) 990-0363 FAX

REQUEST FOR A ROTATING RATING PHYSICIAN OR CHIROPRACTOR
Name of Requestor: Address: City: Requestor is: Date: Phone: FAX: Zip: Injured Employee; Other (Specify)

State: Insurer/Third-Party Administrator; *Injured Employee's Attorney or Representative; *Please provide a signed release or power of attorney Insurer/Third-Party Administrator/ Association of Self-Insured Employers Name: Self-Insured Employer's Name: Employer Name: Injured Employee's Name: Injured Employee's Address: State: City: Claim Number: Social Security Number: -

Certificate #: Certificate #:

Zip: Date of Injury:

Stable & Ratable Received: Body Part(s) Codes: Body Part(s) to be evaluated Diagnosis: Name(s) of Doctor(s) who reviewed for possible PPD

INSURER'S INITIAL REQUEST Name(s) of Treating & Evaluating Doctor(s):

If a specific specialty is ordered by a hearing or appeals officer, the decision must be attached

FOR ADDITIONAL RATING PHYSICIAN/CHIROPRACTOR REQUESTS ONLY Date(s) of prior PPD Evaluation(s): Prior Rating Doctor(s): Name of Treating Physician(s)/Chiropractor(s): Body Part(s) Codes: Body Part(s) to be evaluated: Diagnosis: Reason for additional request:
If a specific specialty is ordered by a hearing or appeals officer, the decision must be attached

INSURER AND INJURED EMPLOYEE ASSIGNMENT/AGREEMENT OF RATER Assigned or Agreed by: Date of Assignment/Agreement: Physician/Chiropractor Assigned or Mutually Agreed to: Assigned Rating Physician/Chiropractor's Phone Number: **Notice to requestor: Hard copy will not follow by mail. Compliance with NAC 616C.103(3)c(1)(2)(3)(4)(5) is required D-35 (rev 06/09)