Failure To Timely Act (Petition Alleging Employer Or Its Claim Administrator)

Form OIC-WC-1 West Virginia Workers' Compensation Employees' and Physicians' Report of Occupational Injury or Disease PLEASE PRINT OR TYPE Section I Insurer: 1. Name: (Last): 2. Address: City: 5. Date of Birth: / / / State: Employee's Claim Information Third-Party Administrator: (First): 3. Telephone: ( Zip: M Time: / no / F a.m. p.m. 4. Social Security No.: 7. Marital Status: 9. Time You Began Work on Date of Injury: a.m. p.m. / / (M.I): ) - 6. Sex: / 8. Date of Injury or Last Exposure: 10. Date You Stopped Working Due to Injury: 11. Have You Retired? 12. Employer's Name: Address: City: 13. Job Title/Description: 14. Body Part(s) Injured: yes If %22yes,%22 what was the date you retired: Supervisor's Name: State: Zip: Telephone: ( ) - 15. Describe How Your Injury Occurred (Specify the cause, what you were doing, and equipment/objects involved): 16. Did Injury Occur on Employer's Property? Yes No Address where injury occurred: 17. Please Identify Any Witnesses to Your Injury: I certify that the above is true and correct to the best of my knowledge. I am aware the law provides for severe penalties if I knowingly and with fraudulent intent withhold facts or make false statements in order to obtain or increase benefits to which I am not entitled. By signing this application, I hereby authorize any physician, chiropractor, surgeon, practitioner or other healthcare provider, any hospital, including Veterans' Administration or governmental hospital, and medical service organization, any insurance company, any law enforcement or military agency, any government benefit agency including the Social Security Administration, or any other institution or organization to release to each other, any medical or other information, including benefits paid or payable, pertinent to this injury or disease, except information relative to the diagnosis, treatment and/or counseling for HIV/AIDS, psychological conditions, and/or alcohol or substance abuse, for which I must give specific authorization. A Photostat of this authorization shall be as valid as the original. Employee's Signature: ________________________________________________________________________ Date: _______/ ________/ _______ Section II 1. Name of Physician/Hospital: 3. Address: City: 4. Date of Initial Treatment: All Information Must Be Completed by Initial Healthcare Provider 2. FEIN/Social Security No.: - State: / / Zip: Telephone: ( ) / / - 5. Date Patient May Return to Work: 6. Have you advised the patient to remain off work 4 or more days? Yes. Indicate dates: from to No. If %22no,%22 is the patient capable of Full Duty Modified Duty limitations/restrictions: 7. Condition is a direct result of: Occupational Injury? Yes If the patient is capable of returning to modified duty, specify any Occupational Disease? Non-Occupational Condition? 8. Did this injury aggravate a prior injury/disease? 9. Description of injury or occupational disease: 10. Body part(s) injured: No. If Yes, explain: 11. ICD9-CM Diagnosis Code(s) in order of severity: 12. Name of physician referred to: 13. If the patient was hospitalized, where? I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge I have been informed of my responsibilities under West Virginia's Workers' Compensation Law and agree to abide by such in the administration of services provided thereunder. I understand the submission of false statements or billing may result in prosecution under state and federal law. I further agree to release any office notes/test results immediately to the employer or their representative. Signature: _______________________________________________________________________________________ Date: ______/______/________ American LegalNet, Inc. www.FormsWorkFlow.com