Free Form 120EX - Kentucky

Form 120EX Expedited Determination Revised May 1, 2008

COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS' CLAIMS 657 CHAMBERLIN AVENUE FRANKFORT, KENTUCKY 40601 CLAIM NO. REQUEST FOR EXPEDITED DETERMINATION OF MEDICAL ISSUE
MOVANT
vs.
Name Street Address City/State/Zip Code Name Street Address City/State/Zip Code

RESPONDENT

**********************

PATIENT
Name Street Address City/State/Zip Code Date of Injury Social Security # Name Street Address City/State/Zip Code

EMPLOYER

INSURANCE COMPANY
Name Street Address City/State/Zip Code

Comes the movant and request the Department of Workers' Claims to assign this request for expedited determination of medical issue to an Administrative Law Judge for a decision. In support of this request, the movant files herewith sworn affidavit(s) showing work relatedness and medical necessity, and setting forth the nature of the dispute and facts sufficient to show that the movant is entitled to the relief sought. This information is true and accurate according to my knowledge and belief.

Attorney for Movant (if represented)
Name Street Address City/State/Zip Code

_____________________________________________
Movant's Signature

Subscribed and sworn to before me this _____ day of ___________________, 20_______ ________________________________________________ Notary Public Signature My Commission Expires: _____________________________County: ___________________

Note: The respondent and all other parties have 10 days in which to file a response pursuant to 803 KAR 25:012.

Copies of responses must be delivered to the Department of Workers' Claim, Attention: Case Files, 657 Chamberlin Avenue, Frankfort, Kentucky 40601 and to all parties. Notice: Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

CERTIFICATE OF SERVICE
As required by 803 KAR 25:012, copies must be served on all parties. I certify that true copies of this form and all attachments have been deposited in the United States mail today to the Department of Workers' Claims, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601, and to the following individuals or entities:

Please list party, name and address
Party Name Street Address City/State/Zip Code

Party Name Street Address City/State/Zip Code

Party Name Street Address City/State/Zip Code

Party Name Street Address City/State/Zip Code

Party Name Street Address City/State/Zip Code

_____________________________________________
Date Movant's Signature