Free K-WC E 4 - Application For Post Award Medical (Rev. 05-07) - Kansas

800 S.W. Jackson Street, Suite 600, Topeka, KS 66612-1227 phone ­ 785-296-3441 · fax ­ 785-296-8580 web site ­ www.dol.ks.gov

Division of Workers Compensation Kansas D epartment of Labor

DO NOT WRITE IN THIS SPACE

Docket Number (required): ______________________________________ Phone Number: ______________________________________________ Employee: __________________________________________________ Employee E-mail Address: _____________________________________ Employer: __________________________________________________

APPLICATION FOR POST AWARD MEDICAL
(Date of Award or Order)

Employee applies for post award medical treatment authorized by the decision entered on___________________________ 1. State the nature of medical care sought:______________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 2. The parties shall meet and confer prior to the scheduled hearing. 3. If the party is represented by an attorney, this form shall be signed by at least one attorney of record as required by K.S.A. 44-536a(a). 4. Are you interested in going through the Workers Compensation Mediation Process? Yes No

Applicant's Signature: ___________________________________________________________________ Address: _____________________________________________________________________________ Signed this _______ day of ______________________________, 20_____ DO NOT WRITE IN THIS SPACE
Attorney's Signature:___________________________________________ Attorney's Printed Name:________________________________________ Address:______________________________________________________ ____________________________________________________________ E-mail Address:_______________________________________________
(for purposes of hearing notices)

Telephone Number: (_________)__________________________________ Kansas Supreme Court Number:__________________________________ Federal Privacy Act Disclosure Section 7(a)(2)(B)

The mandatory requirement that social security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of social security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the social security number. K-WC E-4 (Rev. 5-07)