Dependents Claim For Death Benefits {C-35}

WORKERS' COMPENSATION COMMISSION DEPENDENT'S CLAIM FOR DEATH BENEFITS Instructions: The form must be completed in entirety pursuant to the Labor and Employment Article, §§ 9-683.1 through 9-683.5, Annotated Code of Maryland and COMAR 14.09.01.06-1 and must be signed. Name of Deceased: First Mailing Address: City State ZIP Code: Middle Last Existent WCC Claim Number of the Deceased Individual Filing Claim: Street/Mailing Address: City Telephone Number: ( ) State ZIP Code: Relationship to Dependent(s): Employer of Deceased: Mailing/Street Address: City Telephone Number: ( Date of Injury: State Cause of Injury or Disease: Address Where Injured: City Cause of Death: Injury State Disease Relationship to the Deceased (Spouse, Child, Other, etc.) State ) ZIP Code: Federal Employer ID (FEIN) Date of Death: ZIP Code: Dependent Name (a) (b) (c) (d) (e) I hereby make claim as, or on behalf of, a Dependent of the above named Deceased employee and in support thereof make the foregoing statement of facts. Signature of Person Filing this Claim Date 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC C35 (10/2011) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com ALL PARTIES' REQUIRED INFORMATION DECEASED INFORMATION Name Social Security No. Date of Birth Average Weekly Wage* Occupation (e.g. police officer, firefighter) DEPENDENT(S) INFORMATION (a) Name Social Security No. Date of Birth Average Weekly Wage* Street/Mailing Address City State ZIP code (b) Name Social Security No. Date of Birth Average Weekly Wage* Street/Mailing Address City State ZIP code (c) Name Social Security No. Date of Birth Average Weekly Wage* Street/Mailing Address City State ZIP code (d) Name Social Security No. Date of Birth Average Weekly Wage* Street/Mailing Address City State ZIP code (e) Name Social Security No. Date of Birth Average Weekly Wage* Street/Mailing Address City State ZIP code *Average Weekly wage at the time of injury or disablement, see COMAR14.09.01.07 MD WCC C35 (10/2011) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Pursuant to Labor and Employment Article, §§ 9-709, 9-710, and 9-711, Annotated Code of Maryland, and COMAR 14.09.01.06, this authorization must be signed and filed with the Workers' Compensation Commission of Maryland in conjunction with any claim amendment form. A. Person Covered by Authorization This document authorizes the disclosure of protected health information regarding: Name of Deceased Employee Date of Birth Social Security Number B. Purpose of Disclosure This document authorizes the disclosure of protected health information for the purpose of processing, adjudicating and resolving workers' compensation claims. C. Entities Authorized to Make Disclosure This document authorizes any health plan, physician, health care professional, dentist, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to the deceased employee or on my behalf to disclose the deceased employee's protected health information consistent with this directive. D. Entities Authorized to Receive Protected Health Information This document authorizes the disclosure of the deceased employee's protected health information to the following entities and their agents: dependent claimant's or the deceased employee's attorney, the deceased employee's employer, the employer's workers' compensation insurer or any agent thereof. E. Information to be Disclosed This document authorizes the entities listed in C to disclose protected health information that is relevant to the member of the body that was injured as indicated on the claim form. The protected health information that may be disclosed includes, but is not limited to: history, findings, office and patient charts, files, examination and progress notes, and physical evidence. F. I understand that I may revoke this authorization by giving written notice to all parties in my claim for workers' compensation death benefits, except to the extent that this authorization has already been acted on prior to receipt of my revocation. I understand that the information disclosed by this authorization may be subject to re-disclosure by the recipient to a medical manager, health care professional or registered rehabilitation practitioner, and others consistent with state and federal law. By signing this form, I am authorizing the disclosure of the deceased employee's protected health information. This authorization is valid for one year from the date the amended claim is filed. Name of Signature of Dependent Claimant or Authorized Representative Statement of Authorization: I am authorized to sign or act on behalf of the dependent claimant because: Date A photocopy, facsimile or electronic transmission of this signed authorization form is valid. Claim Filing Date: WCC Dependent Claim Number: MD WCC C35 (10/2011) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: IMPORTANT: It is the Dependent's or the Authorized Representative's responsibility to maintain a current mailing address with the Commission. The Commission Claim Number when assigned should be included on all forms or correspondence. Disclosure Pursuant to COMAR 01.01.1983.18 1. The personal information requested on this form is intended to be used in processing your claim under the Maryland workers' compensation laws. 2. Failure to provide the information requested may result in your claim being rejected or a delay in the processing of your claim. 3. You may have a right to inspect, amend and correct the information provided on this form pursuant to State Government Article, §10-624, Maryland Code Annotated. 4. This form will be made part of your claim file. Portions of your claim file may be subject to public inspection. 5. The information contained on this form is routinely shared with State, Federal or local agencies. Claim Filing Instructions (COMAR 14.09.01.06) ONLY an ORIGINAL claim form obtained from the Workers' Compensation Commission with original signature(s) will be accepted. This form may not be submitted as a photocopy or recreated on office systems; reproductions will be returned to the sender without processing the claim. The Commission does not accept any claim forms, documents or claim-related information via facsimile (FAX) or email (attachmen