SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041
WORKERS' COMPENSATION COMPLAINT
CLAIMANT'S (INJURED WORKER) NAME AND ADDRESS CLAIMANT'S ATTORNEY'S NAME, ADDRESS, AND TELEPHONE NUMBER
EMPLOYER'S NAME AND ADDRESS (at
time of injury)
WORKERS' COMPENSATION INSURANCE CARRIER'S (NOT ADJUSTOR'S) NAME AND ADDRESS
CLAIMANT'S SOCIAL SECURITY NO.
DATE OF INJURY OR MANIFESTATION OF OCCUPATIONAL DISEASE
STATE AND COUNTY IN WHICH INJURY OCCURRED
WHEN INJURED, CLAIMANT WAS EARNING AN AVERAGE WEEKLY WAGE OF: $_______________, PURSUANT TO IDAHO CODE § 72-419
DESCRIBE HOW INJURY OR OCCUPATIONAL DISEASE OCCURRED (WHAT HAPPENED)
NATURE OF MEDICAL PROBLEMS ALLEGED AS A RESULT OF ACCIDENT OR OCCUPATIONAL DISEASE
WHAT WORKERS' COMPENSATION BENEFITS ARE YOU CLAIMING AT THIS TIME?
DATE ON WHICH NOTICE OF INJURY WAS GIVEN TO EMPLOYER
TO WHOM NOTICE WAS GIVEN
HOW NOTICE WAS GIVEN:
OTHER, PLEASE SPECIFY
ISSUE OR ISSUES INVOLVED
DO YOU BELIEVE THIS CLAIM PRESENTS A NEW QUESTION OF LAW OR A COMPLICATED SET OF FACTS?
NO IF SO, PLEASE STATE WHY.
NOTICE: COMPLAINTS AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND MUST BE IN ACCORDANCE WITH IDAHO CODE § 72-334 AND FILED ON FORM I.C. 1002
IC1001 (Rev. 3/01/2008)
(COMPLETE OTHER SIDE)
Complaint Page 1 of 3
PHYSICIANS WHO TREATED CLAIMANT (NAME AND ADDRESS)
WHAT MEDICAL COSTS HAVE YOU INCURRED TO DATE? WHAT MEDICAL COSTS HAS YOUR EMPLOYER PAID, IF ANY? $__________________ WHAT MEDICAL COSTS HAVE YOU PAID, IF ANY? $__________________
I AM INTERESTED IN MEDIATING THIS CLAIM, IF THE OTHER PARTIES AGREE.
SIGNATURE OF CLAIMANT OR ATTORNEY: __________________________________________________________ TYPE OR PRINT NAME: ______________________________________________________________________________
PLEASE ANSWER THE SET OF QUESTIONS IMMEDIATELY BELOW ONLY IF CLAIM IS MADE FOR DEATH BENEFITS
NAME AND SOCIAL SECURITY NUMBER OF PARTY FILING COMPLAINT DATE OF DEATH RELATION TO DECEASED CLAIMANT
WAS FILING PARTY DEPENDENT ON DECEASED? YES NO
DID FILING PARTY LIVE WITH DECEASED AT TIME OF ACCIDENT? YES NO
CLAIMANT MUST COMPLETE, SIGN AND DATE THE ATTACHED MEDICAL RELEASE FORM
CERTIFICATE OF SERVICE
I hereby certify that on the ____ day of __________, 20___, I caused to be served a true and correct copy of the foregoing Complaint upon: EMPLOYER'S NAME AND ADDRESS _______________________________________ _______________________________________ _______________________________________ via: personal service of process regular U.S. Mail SURETY'S NAME AND ADDRESS _____________________________________ _____________________________________ _____________________________________ via: personal service of process regular U.S. Mail ________________________________________________________ Signature ________________________________________________________ Print or Type Name
NOTICE: An Employer or Insurance Company served with a Complaint must file an Answer on Form I.C. 1003 with the Industrial Commission within 21 days of the date of service as specified on the certificate of mailing to avoid default. If no answer is filed, a Default Award may be entered! Further information may be obtained from: Industrial Commission, Judicial Division, P.O. Box 83720, Boise, Idaho 83720-0041 (208) 334-6000.
(COMPLETE MEDICAL RELEASE FORM ON PAGE 3) Complaint Page 2 of 3
Patient Name:______________________________ Birth Date:_________________________________ Address:___________________________________ Phone Number:_____________________________ SSN or Case Number:________________________
(Provider Use Only) Medical Record Number:_______________________ Pick up Copies Fax Copies #________________ Mail Copies ID Confirmed by:______________________________
AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION I hereby authorize ___________________________________________ to disclose health information as specified:
Provider Name must be specific for each provider
To:_________________________________________________________________________________________ Insurance Company/Third Party Administrator/Self Insured Employer/ISIF, their attorneys or patient's attorney ____________________________________________________________________________________________ Street Address ____________________________________________________________________________________________ City State Zip Code Purpose or need for data:___________________________________________________________
(e.g. Worker's Compensation Claim )
Information to be disclosed: Date(s) of Hospitalization/Care:_____________________ Discharge Summary History & Physical Exam Consultation Reports Operative Reports Lab Pathology Radiology Reports Entire Record Other: Specify_____________________________________________ I understand that the disclosure may include information relating to (check if applicable): AIDS or HIV Psychiatric or Mental Health Information Drug/Alcohol Abuse Information I understand that the information to be released may include material that is protected by Federal Law (45 CFR Part 164) and that the information may be subject to redisclosure by the recipient and no longer be protected by the federal regulations. I understand that this authorization may be revoked in writing at any time by notifying the privacy officer, except that revoking the authorization won't apply to information already released in response to this authorization. I understand that the provider will not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. Unless otherwise revoked, this authorization will expire upon resolution of worker's compensation claim. Provider, its employees, officers, copy service contractor, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized by me on this form and as outlined in the Notice of Privacy. My signature below authorizes release of all information specified in this authorization. Any questions that I have regarding disclosure may be directed to the privacy officer of the Provider specified above. _____________________________________________________________________________________________ Signature of Patient Date _____________________________________________________________________________________________ Signature of Legal Representative & Relationship to Patient/Authority to Act Date _____________________________________________________________________________________________ Signature of Witness Title Date
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