Request For Rotating Rating Physician Or Chiropractor {D-35}

D-35 - REQUEST FOR A ROTATIING PHYSICIAN OR CHIROPRACTOR. This form is used for workers' compensation cases in the State of Nevada. The form requires detailed information about the requestor, including their name, contact information, and request date. It also includes claim information such as the insurer or third-party administrator (TPA), claim number, date of injury, employer details, and employee information (name, social security number, birth date, city, state, and zip code). The form specifically asks for information related to the treating or evaluating physician(s) or chiropractor(s). This includes providing specific body part codes and injury sides, along with diagnoses and any comments regarding the case. If there were previous Permanent Partial Disability (PPD) evaluations, the form requires details about the prior rating physician(s) or chiropractor(s) and the reason for the additional PPD request. If the request is due to mutual agreement, information about the PPD rating physician/chiropractor, injured employee/representative, and insurer/TPA representative must be provided. The form also allows for attachments related to court-ordered decisions if applicable. www.FormsWorkflow.com