Last updated: 12/2/2010
Notice Of Intention To Close Claim {D-31}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
Date: To: Address: Re: Claim No: Date of Injury: Employer: Insurer/TPA: NOTICE OF INTENTION TO CLOSE CLAIM (Pursuant to NRS 616C.235) After a careful and thorough review of your workers' compensation claim, it has been determined that all benefits have been paid and your claim will be closed effective seventy (70) days from the date of this notice. Based on the available medical information, the claim will be closed without a Permanent Partial Disability (PPD) evaluation as there is no possibility of a permanent impairment of any kind. Your file reflects that you are not presently undergoing any medical treatment; however, if you are scheduled for future medical appointments, please advise this office immediately. Nevada Revised Statute (NRS) 616C.390 defines your right to reopen your claim. You must make a written request for reopening and your doctor must submit a report relating your problem to the original industrial injury. The report must state that your condition has worsened since the time of claim closure and that the condition requires additional medical care. Reopening is not effective prior to the date of your request for reopening unless good cause is shown. Upon such showing by your doctor, the cost of emergency treatment shall be allowed. If you disagree with the above determination, you do have the right to appeal. If your appeal concerns "accident benefits" (medical treatment or supplies) and your insurer has contracted with an organization for managed care, complete the bottom portion of this notice and send it to your insurer no later than fourteen (14) days after the date of this notice. If your appeal concerns "compensation benefits," or if no organization for managed care is involved in your claim, complete the bottom portion of this notice and send it to the State of Nevada, Department of Administration, Hearings Division. Your appeal must be filed within seventy (70) days after the date on which the notice of the insurer's final determination was mailed. Department of Administration Hearings Division 1050 E. William Street, Ste. 400 Carson City, NV 89710 (775) 687-8440 Reason for appeal: OR Department of Administration Hearings Division 2200 S. Rancho Drive, Suite 210 Las Vegas, NV 89102 (702) 486-2525 Signature Retain a copy of this notice for your records. c.: Enclosure Date D-31 (rev. 10/10) American LegalNet, Inc. www.FormsWorkFlow.com
Related forms
-
Application For Reimbursement Of Claim Related Travel Expenses
Nevada/Workers Comp/ -
Assignment To Division For Workers Compensation Benefits
Nevada/Workers Comp/ -
Authorization Request For Additional Chiropractic Treatment
Nevada/Workers Comp/ -
Authorization Request For Additional Physical Therapy Treatment
Nevada/Workers Comp/ -
Election For Nevada Workers Compensation Coverage For Out Of State Injury
Nevada/Workers Comp/ -
Election Of Coverage By Employer And Employer Withdrawal Of Election Of Coverage
Nevada/Workers Comp/ -
Employees Claim For Compensation - Uninsured Employer
Nevada/Workers Comp/ -
Employees Declaration Of Election To Report Tips
Nevada/Workers Comp/ -
Employees Election To Reject Coverage And Election To Waive Rejection Of Coverage For Excluded Persons
Nevada/Workers Comp/ -
Fatality Report
Nevada/Workers Comp/ -
Health Insurance Claim Form
Nevada/Workers Comp/ -
Insurers Subsequent Injury Checklist
Nevada/Workers Comp/ -
Interest Calculation For Compensation Due
Nevada/Workers Comp/ -
Lump Sum Rehabilitation Agreement
Nevada/Workers Comp/ -
Notice Of Election For Compensation Benefits Under Uninsured Employer Statutes
Nevada/Workers Comp/ -
Notice Of Intention To Close Claim
Nevada/Workers Comp/ -
Permanent Total Disability Report Of Employment
Nevada/Workers Comp/ -
Rehabilitation Lump Sum Request
Nevada/Workers Comp/ -
Request For Hearing - Contested Claim
Nevada/Workers Comp/ -
Request For Hearing - Uninsured Employer
Nevada/Workers Comp/ -
Sole Proprietor Coverage
Nevada/Workers Comp/ -
Temporary Partial Disability Calculation Worksheet
Nevada/Workers Comp/ -
Wage Calculation Form For Claims Agents Use
Nevada/Workers Comp/ -
Policy Termination-Cancelation-Reinstatement Notice
Nevada/Workers Comp/ -
Proof Of Coverage Notice
Nevada/Workers Comp/ -
Request For Reimbursement Of Expenses For Travel And Lost Wages
Nevada/Workers Comp/ -
Complaint Form (Northern Inusurers)
Nevada/Workers Comp/ -
Complaint Form (Southern Insurers)
Nevada/Workers Comp/ -
Index Of Claims System Claim Registration
Nevada/Workers Comp/ -
Employers Report Of Industrial Injury Or Occupational Disease
Nevada/Workers Comp/ -
Notice Of Injury Or Occupational Disease Incident Report
Nevada/Workers Comp/ -
Reaffirmation Retraction Of Lump Sum Request
Nevada/Workers Comp/ -
Injured Employees Request For Compensation
Nevada/Workers Comp/ -
Firefighters And Police Officers Medical History
Nevada/Workers Comp/ -
Firefighters And Police Officers Lung Examination
Nevada/Workers Comp/ -
Firefighters And Police Officers Limited Heart Examination
Nevada/Workers Comp/ -
Firefighters And Police Officers Hearing Examination
Nevada/Workers Comp/ -
Occupational Disease Claim Report
Nevada/Workers Comp/ -
Permanent Partial Disability Award Calculation Work Sheet
Nevada/Workers Comp/ -
Permanent Partial Disability Award Calculation Work Sheet For Disability Over 30 Percent Body Basis
Nevada/Workers Comp/ -
Election Of Lump Sum Payment Of Compensation
Nevada/Workers Comp/ -
Election Of Lump Sum Payment Of Compensation For Disability Greater Than 30 Percent
Nevada/Workers Comp/ -
Firefighters And Police Officers Extensive Heart Examination
Nevada/Workers Comp/ -
Notice Of Claim Acceptance
Nevada/Workers Comp/ -
Employees Claim For Compensation Report Of Initial Treatment
Nevada/Workers Comp/ -
Employers Wage Verification Form
Nevada/Workers Comp/ -
Affirmation Of Compliance With Mandatory Industrial Insurance Requirements
Nevada/Workers Comp/ -
Request For Additional Medical Information And Release Form
Nevada/Workers Comp/ -
Physician And Chiropractor Progress Report Certification Of Disability
Nevada/Workers Comp/ -
Request For Rotating Rating Physician Or Chiropractor
Nevada/Workers Comp/ -
Informational Poster - Displayed By Employer
Nevada/Workers Comp/ -
Permanent Work Related Mental Impairment Rating Report Work Sheet
Nevada/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!