STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION ___________________________________, Worker, v. ____________________________________, and ____________________________________, Employer/Insurer. WORKERS' COMPENSATION COMPLAINT 1. 2. Type of injury: ___Occupational Injury ___Occupational Disease Worker's Full Name: _____________________________________________________________ Mailing Address: _____________________________________________________________ City/State/Zip: _____________________________________________________________ Telephone No.: (____)________________________________________________________ Worker's date of birth: _____/_____/_____ Age: ____ Sex: ____M ____F Worker's Social Security Number: _______-______-_______ Full Name of Employer: _____________________________________________________________ Employer's Address: _____________________________________________________________ City/State/Zip: _____________________________________________________________ Telephone No.: (___)_________________________________________________________ Insurance Carrier: _____________________________________________________________ Address: _____________________________________________________________ City/State/Zip: _____________________________________________________________ Telephone No.: (___)_________________________________________________________ Date of Accident: _____________________________________________________________________ a. City and County of accident:_____________________________________________________ b. Worker's job at time of accident:__________________________________________________ c. Worker's wages at time of accident: $____hour $____ bi-weekly $____month $____year d. How did the accident occur:______________________________________________________ e. Part(s) of the body injured:_______________________________________________________ f. Type of injury/diagnosis:_________________________________________________________ g. Name and address of treating Doctor(s):_____________________________________________ _____________________________________________________________________________ h. First date Worker was unable to perform job duties:____________________________________ i. Date of maximum medical improvement:____________________________________________ j. Impairment rating:_______________________ Doctor's Name:__________________________ k. Has Worker been released to work by a Doctor? ___Yes ___No If yes, please indicate the date Worker was released to work:_____________________________ l. Has Worker returned to work since the accident? ___Yes ___No If yes, please indicate the date Worker returned to work:_________________________________ m. Name and address of current Employer:______________________________________________ n. Highest level of school completed by Worker:_________________________________________ a. What benefit or relief is being sought? 1. Complaints by Worker: ___Temporary Total Disability ___Death Benefits ___Permanent Total Disability ___Attorney Fees ___Permanent Partial Disability ___Disfigurement ___Safety Device Increase (name device):____________________________________________ ___Mental Impairment: ___Primary ___Secondary ___Medical Benefits (list here or attach unpaid bills):___________________________________ ___Determination of: ____Bad Faith/Unfair Claims Processing _____Fraud or ____Retaliation WCA No.: _________________
3. 4. 5.
___Other (specify):_______________________________________________________________ 2. Complaints by Employer: ___Determination of Compensability/Benefits ___Safety Device Decrease (name device):___________________________________________ ___Reimbursement Right ___Credit for Overpayment ___Suspension or Reduction of Benefits (state grounds):________________________________ ______________________________________________________________________________ Other (specify):__________________________________________________________________ b. State all reasons supporting this complaint (be specific; use additional pages, if necessary): ______________________________________________________________________________________ ______________________________________________________________________________________ Is an interpreter needed for the hearings on this complaint? ___Yes ___No. If yes, what language? _______________________ If yes, Employer must furnish. If you have questions, call 1-800-255-7965, Mediation Bureau.
________________________________________ Worker's Signature ________________________________________ Date
__________________________________________________ Attorney's Signature __________________________________________________ Worker/Attorney's Name __________________________________________________ Worker/Attorney's Address __________________________________________________ Worker/Attorney's City, State, Zip __________________________________________________ Worker/Attorney's Telephone & Fax Number
A Summons for each adverse party and insurer shall be filed with the Complaint. If the Worker is filing this Complaint, an Authorization to Release Medical Information form shall be filed with the Complaint.
STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION _________________________________________, Worker, v. _________________________________________, and _________________________________________, Employer/Insurer. WCA No.:__________________
SUMMONS FOR WORKERS' COMPENSATION COMPLAINT TO: ______________________________________ ______________________________________ ______________________________________ GREETINGS: You are directed to serve a written response to the Workers' Compensation Complaint not less than five (5) days prior to the mediation conference, and file the same, as provided by law. You are notified that, unless you serve and file a responsive pleading or motion, the filing party may apply to the Workers' Compensation Administration for the relief demanded in the Workers' Compensation Complaint. Worker or filing party's representative: Address of Worker or filing party's representative: ___________________________________________ ___________________________________________ ___________________________________________ ____________________________________ ____________________________________ ____________________________________
WITNESSED AND SEALED BY THE CLERK OF THE WCA
(SEAL) By:_______________________________________________ Date:______________________________________________
(EACH ADVERSE PARTY MUST BE NAMED IN THE SUMMONS)
WORKER'S AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WORKERS' COMPENSATION PURPOSES (HIPAA COMPLIANT) I, (Print Worker's Name) ________________________________________________________, hereby authorize the health care provider (HCP) (the name of HCP is optional and not required for release of medical information) (Print Health Care Provider's Name) _____________________________________________ the use or disclosure of my health information as described in this authorization. 1. INFORMATION WCA No. _________________________
Date of Birth ___________________ Date of Injury ___________________ SSN _________________________ Address ______________________________________________________ Phone ________________________ Worker's representative, if any: ___________________________________ Phone ________________________ Address: ___________________________________________________________________________________ 2. RELEASE
I authorize the Health Care Provider (HCP) or any member or employee of its office or association who has examined or treated me, as well as any hospital or treatment facility in which I have been a patient, to disclose and release complete and legible copies of any and all information concerning my physical or psychiatric condition, care and treatment, to my employer, ______________________________________________________, and/or its insurance carrier, __________________________________________________, and/or their attorneys, and/or duly authorized representatives of the New Mexico Workers' Compensation Administration and its current medical cost containment contractor or their duly authorized agents. Copies of all documentation released pursuant to this authorization shall be sent to the agency requesting the information and to me or my representative as listed above. 3. I understand the following information will be released pursuant to a work-related/occupational injury or illness/workers' compensation claim: medical reports; clinical notes; nurses' notes; patient's history of injury; subjective and objective complaints; x-rays; test results; interpretation of x-rays or other tests (including a copy of the report); diagnosis and prognosis; hospital bills; bills for services the HCP has rendered; payments received; and any other relevant and material information in the HCP's possession. This Authorization also includes, if applicable, any hospital operational logs, emergency logs, tissues committee reports, psychiatric reports and records, physical therapy records, and all outpatient records. This release may also be used to request a Form Letter to HCP as approved by the Workers' Compensation Administration. I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law. CONDITIONS 4. I understand the purpose of this request is to determine the proper level of workers' compensation benefits and may include information regarding any of the following: to determine my occupational injury or illness status; to determine my eligibility for workers' compensation benefits; to determine my current and future medical status after occupational injury; to determine my current medical status and/or return-to-work capability. 5. Right to revoke: I understand I have the right to revoke this authorization at any time by notifying the company named in Paragraphs 1 and 2. I understand that the revocation is only effective after it is received and logged by that company and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation. I further understand that my revocation of this authorization may affect my ability to receive occupational injury or workers' compensation benefits governed by this revocation. 6. I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.
7. I understand that information to be released pursuant to a work-related/occupational injury or illness/workers' compensation claim may also be released to WCA and its current medical cost containment contractor or their duly authorized agents. 8. I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records. 9. A photostatic or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed. 10. This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted. 11. I understand I am entitled to a copy of this authorization and to any records provided hereunder. I am requesting a copy of this authorization Yes No - If Yes, I have received a copy _______ (initial) I understand this authorization will expire within six (6) months of the date I signed it, unless I revoke it earlier, pursuant to Paragraph 5.
Signature of Employee __________________________________________ Date __________________________ Personal Representative Section: If a personal representative executes this form, that representative warrants that he or she has authorization to sign this form on the basis of (print detailed basis for representation): _________________________________________ _____________________________________________________________________________________________. Signature of Personal Representative _______________________________ Date _________________________