Motion For Emergent Medical Treatment {WC-383}

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION P.O. Box 381 Trenton, NJ 08625-0381 WC-383 (5-14) MOTION FOR EMERGENT MEDICAL TREATMENT Pursuant to N.J.S.A. 34:15-15.3 NAME: ATTORNEY FOR PETITIONER / APPLICANT ADDRESS: Case No. : Vicinage: NAME: PETITIONER / APPLICANT ADDRESS: TELEPHONE NUMBER (AREA CODE): vs NAME: RESPONDENT ADDRESS: NAME : INSURANCE CARRIER ADDRESS: NAME: ATTORNEY FOR RESPONDENT ADDRESS: CLAIM NUMBER: TELEPHONE NUMBER (AREA CODE): PLEASE TAKE NOTICE that Petitioner seeks emergent medical care pursuant to N.J.S.A. 34:15-15.3. Attached are the required supporting documents: A copy of the Claim Petition A copy of the Answer (if received) A statement by the petitioner or the petitioner's attorney of the dates and to whom specific requests for authorized medical care were made. A statement by a physician that includes petitioner's need of emergent medical care, a delay in treatment will result in irreparable harm or damage to the petitioner and the specific nature of the irreparable harm or damage. All relevant medical records in the possession of the petitioner. PETITIONER verifies that service of this motion and supporting materials has been made (check one): If an answer has been filed, by fax and one-day delivery service on respondent's attorney (unless the respondent attorney is electronically served the Motion by the Division). If no answer has been filed, on the petitioner's employer by personal service or by fax and one-day delivery service and if insured by fax and one-day delivery service on the employer's insurance company contact person (listed on Division's website). If employer is uninsured, on the Uninsured Employer's Fund by fax and one-day delivery service. The personal service, electronic service, fax service or the date of one-day delivery service, whichever is later shall be considered the date of service. Respondent shall file an answer to the motion within 5 calendar days from the date of service and may have an examination of petitioner conducted within 15 calendar days from the date of service. American LegalNet, Inc. www.FormsWorkFlow.com The following additional information is required for motion scheduling when an answer to the Claim Petition has not been filed: Employer Telephone Number: __________________ Fax (If known): ___________________ Insurance Company or Self-Insurer Contact Person: _______________________________________ Telephone Number: ____________________ Fax: _______________________ Motions for Emergent Medical Care must be filed in the District Office (vicinage) the claim petition has been assigned or will be assigned. See N.J.A.C. 12:235-3.1. If no claim petition has been filed, one must be filed simultaneously in the Trenton Central Office, Division of Workers' Compensation, P.O. Box 381, Trenton, NJ 08625. ______________________________________________ ATTORNEY FOR PETITIONER Dated: __________________ American LegalNet, Inc. www.FormsWorkFlow.com