Workers Compensation Complaint {IC-1001}

SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041 WORKERS COMPENSATION COMPLAINT CLAIMANTS (INJURED WORKER) NAME AND ADDRESS CLAIMANTS ATTORNEYS NAME, ADDRESS, AND TELEPHONE NUMBER TELEPHONE NUMBER: EMPLOYERS NAME AND ADDRESS (at time of injury) WORKERS COMPENSATION INSURANCE CARRIERS (NOT ADJUSTORS) NAME AND ADDRESS CLAIMANTS SOCIAL SECURITY NO. CLAIMANTS BIRTHDATE DATE OF INJURY OR MANIFESTATION OF OCCUPATIONAL DISEASE STATE AND COUNTY IN WHICH INJURY OCCURRED WHEN INJURED, CLAIMANT WAS EARNING AN AVERAGE WEEKLY WAGE OF: $_______________, PURSUANT TO IDAHO CODE 72-419 DESCRIBE HOW INJURY OR OCCUPATIONAL DISEASE OCCURRED (WHAT HAPPENED) NATURE OF MEDICAL PROBLEMS ALLEGED AS A RE SULT OF ACCIDENT OR OCCUPATIONAL DISEASE WHAT WORKERS COMPENSATION BENEFITS ARE YOU CLAIMING AT THIS TIME? DATE ON WHICH NOTICE OF INJURY WAS GIVEN TO EMPLOYER TO WHOM NOTICE WAS GIVEN HOW NOTICE WAS GIVEN: ORAL WRITTEN OTHER, PLEASE SPECIFY ISSUE OR ISSUES INVOLVED DO YOU BELIEVE THIS CLAIM PRESENTS A NEW QUESTION OF LAW OR A COMPLICATED SET OF FACTS? YES NO IF SO, PLEASE STATE WHY. NOTICE: COMPLAINTS AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND MUST BE IN ACCORDANCE WITH IDAHO CODE 72-334 AND FILED ON FORM I.C. 1002 IC1001 (Rev. 1/01/2004) (COMPLETE OT HER SIDE) Com p laint Page 1 of 3 Appendix 1 <<<<<<<<<********>>>>>>>>>>>>> 2 PHYSICIANS WHO TREATED CL AIMANT (NAME AND ADDRESS) WHAT MEDICAL COSTS HAVE YOU INCURRED TO DATE? WHAT MEDICAL COSTS HAS YOUR EMPLOYER PAID, IF ANY? $__________________ WHAT MEDICAL COSTS HAVE YOU PAID, IF ANY? $__________________ I AM INTERESTED IN MEDIATING THIS CLAIM, IF THE OTHER PARTIES AGREE. YES NO DATE SIGNATURE OF CLAIMANT OR ATTORNEY PLEASE ANSWER THE SET OF QUESTIONS IMMEDIATELY BELOW ONLY IF CLAIM IS MADE FOR DEATH BENEFITS NAME AND SOCIAL SECURITY NUMBER OF PARTY DATE OF DEATH RELATION TO DECEASED CLAIMANT FILING COMPLAINT WAS FILING PARTY DEPENDENT ON DECEASED? DID FILING PARTY LIVE WITH DECE ASED AT TIME OF ACCIDENT? YES NO YES NO CLAIMANT MUST COMPLETE, SIGN AND DATE THE ATTACHED ME DICAL RELEASE FORM CERTIFICATE OF SERVICE I hereby certify that on the ____ day of __________, 20___, I cauto bsed e served a true and correct copy of the foregoing Complaint upon: EMPLOYERS NAME AND ADDRESS SURETYS NAME AND ADDRESS _______________________________________ _____________________________________ _______________________________________ _____________________________________ _______________________________________ _____________________________________ via: N personal service of process via: N personal service of process N regular U.S. Mail N regular U.S. Mail ________________________________________________________ Signature NOTICE: An Employer or Insurance Company served with a Complaint must file an Answer on Form I.C. 1003 with the Industrial Commission within 21 days of the date of service as specified on the certificate of mailing to avoid default. If no answer is filed, a Default Award may be entere d! Further information may be obtained from: Industrial Commission, Judicial Division, P.O. Box 83720, Boise, Idaho 83720-0041 (208) 334-6000. (COMPLETE MEDICAL RELEASE FORM ON PAGE 3) Complaint Page 2 of 3<<<<<<<<<********>>>>>>>>>>>>> 3INDUSTRIAL COMMISSION Patient Name:______________________________ PO BOX 83720 Birth Date:_________________________________ BOISE ID 83720-0041 Address:___________________________________ Phone Number:_____________________________ SSN or Case Number:________________________ (Provider Use Only) Medical Record Number:_______________________
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Mail Copies ID Confirmed by:______________________________ AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION I hereby authorize ___________________________________________ to disclose health information as specified: Provider Name must be specific for each provider To:_________________________________________________________________________________________ Insurance Company/Third Party Administrator/Self Insured Employer/ISIF, their attorneys or patients attorney ____________________________________________________________________________________________ St reet Address ____________________________________________________________________________________________ City State Zip Code Purpose or need for data:___________________________________________________________ ( e.g. Workers Compensation Claim ) Information to be disclosed: Date(s) of Hospitalization/Care:_____________________ Discharge Summary History & Physical Exam Consultation Reports Operative Reports Lab Pathology Radiology Reports Entire Record Other: Specify_____________________________________________ I understand that the disclosure may include information relating to (check if applicable): AIDS or HIV Psychiatric or Mental Health Information Drug/Alcohol Abuse Information I understand that the information to beleas reed may include material that is protected by Federal Law (45 CFR Part 164) and that the information may be subject to redisclosure by the recipient and no longer be protected by the federal regulations. I understand that this authorization may be revoked in writing at any time by notifying the privacy officer, except that revoking the authzationori wont apply to information already released in response to this authorization. I understand that the provider will not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. Unless otherwise revoked, this authorization will expire upon resolution of workers compensation claim. Provider, its employees, officers, copy service contractor, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized by me on this form and as outlined in the Notice of Privacy. My signature below authorizes release of all information specified in this authorization. Any questions that I have regarding disclosure may be directed to the privacy officer of the Provider specified above. _____________________________________________________________________________________________ Signature of Patient D ate _____________________________________________________________________________________________ Signature of Legal Representative & Relationship to Patient/Authority to Act Date ____________________________________________________________________________