Free D-31 - Nevada

RE:

Claim No: Employer: Insurer: TPA: Date of Injury: Date of Notice:

TO: FROM: NOTICE OF INTENTION TO CLOSE CLAIM (Pursuant to NRS 616C.235) After a careful and thorough review of your workers' compensation claim, it has been determined that all benefits have been paid and your claim will be closed effective seventy (70) days from the date of this notice. Your file reflects that you are not presently undergoing any medical treatment; however, if you are scheduled for future medical appointments, please advise us immediately. Nevada Revised Statute (NRS) 616C.390 defines your right to reopen your claim. You must make a written request for reopening and your doctor must submit a report relating your problem to the original industrial injury. The report must state that your condition has worsened since the time of claim closure and that the condition requires additional medical care. Reopening is not effective prior to the date of your request for reopening unless good cause is shown. Upon such showing by your doctor, the cost of emergency treatment shall be allowed. If you disagree with the above determination, you do have the right to appeal. If your appeal concerns "accident benefits" (medical treatment or supplies) and your insurer has contracted with an organization for managed care, complete the bottom portion of this notice and send it to your insurer no later than fourteen (14) days after the date of this notice. If your appeal concerns "compensation benefits," or if no organization for managed care is involved in your claim, complete the bottom portion of this notice and send it to the State of Nevada, Department of Administration, Hearings Division. Your appeal must be filed within seventy (70) days after the date on which the notice of the insurer's final determination was mailed. Department of Administration Hearings Division 1050 E. William Street, Ste. 400 Carson City, NV 89710 (775) 687-5966 Reason for appeal: OR Department of Administration Hearings Division 2200 S. Rancho Drive, Suite 210 Las Vegas, NV 89102 (702) 486-2525

Signature Retain a copy of this notice for your records. c.: Enclosure

Date D-31 (rev. 10/03)