Free Form NMRP - Kentucky


File Size: 18.5 kB
Pages: 3
File Format: PDF
State: Kentucky
Category: Workers Compensation
Author: kmckenzi
Word Count: 291 Words, 2,885 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.labor.ky.gov/NR/rdonlyres/22E810ED-340D-463D-80DE-A08D1DECD6D8/0/NoticeofFilingofMedicalReport.pdf

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NMRP Notice of Filing of Medical Report April 27, 2000 Edition

COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS CLAIM NO. _____________ BEFORE ______________ PLAINTIFF (EMPLOYEE) VS. NOTICE OF FILING OF MEDICAL REPORT OF DR. _____________________ (DOCTOR'S NAME) DEFENDANT(S) (EMPLOYER) _____________________________ (OTHER DEFENDANTS) _____________________________ (SPECIAL FUND) *************** Comes the plaintiff, , and files the medical report/statement dated (EMPLOYEE) ____________ from Dr. , as evidence on his/her behalf. DWC Medical Qualification Index number is or his/her CV is attached. AFFIDAVIT I, __________________________, do hereby state that the attached medical report is a (EMPLOYEE) true and exact copy of the document supplied to me by Dr. _______________________________. (DOCTOR'S NAME) __________________________________________ (EMPLOYEE'S SIGNATURE) Subscribed and sworn before me on this the ________ day of __________________, 20_______. __________________________________________ NOTARY PUBLIC, KY at Large My Commission expires: ____________________________ County:________________________

Respectfully submitted, __________________________________________ (Employee's Signature) __________________________________________ (Employee's Street Address) __________________________________________ (Employee's City/State/Zip Code)

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 material fact commits a fraudulent insurance act, which is a crime. CERTIFICATE OF SERVICE I certify that the original of this Notice was mailed to the Department of Workers Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky 40601 and copies of this Notice and attachments were mailed to the names and addresses of the parties given below:

Attorney for Employer or Insurance Carrier___________________________________________ if applicable: (Attorney Name or Law Firm) ___________________________________________ (Attorney Address or Law Firm Street Address) ___________________________________________ (Attorney Address, City/State/Zip)

Employer or Insurance Carrier:

___________________________________________ (Company Name or Employer Name) ___________________________________________ (Company or Employer Street Address) ___________________________________________ (Company or Employer City/State/Zip)

Other Parties, if applicable:

___________________________________________ (Name of Party) ___________________________________________ (Party Street Address) ___________________________________________ (Party City/State/Zip)

This _______ day of _____________________, 20_________. __________________________________________ (Employee's Signature)