Request For Expedited Medical Determination

REQUEST FOR EXPEDITED MEDICAL DETERMINATION. This form is used to request an expedited ruling on medical treatment in a workers’ compensation claim. It may be filed by the employee, employer, or another party to secure prompt approval and payment of necessary medical care when delay could cause irreparable harm. The form requires details about the claimant, employer, insurance carrier, injury date, nature of the injury, and body part affected. Supporting attachments include an affidavit establishing eligibility for benefits, proof of notice to the employer, and a physician’s medical report showing the need for urgent treatment. The filing must be served to all parties and submitted electronically or by mail to the Department of Workers’ Claims in Frankfort, KY. A fraud warning is included, and the filer must certify the accuracy of all information. www.FormsWorkflow.com