Utah > Workers Compensation
Medical Treatment Provider List (Adjudication) 307 - Utah
| Medical Treatment Provider List (Adjudication) Form. This is a Utah form and can be used in Workers Compensation . |
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Form 307 3/1/12 MEDICAL TREATMENT PROVIDER LIST Claimant Name _______________________________________ Social Security Number _____________________________ Address________________________________________________ Date of Injury ________________________________________ _________________________________________________________ Employer ____________________________________________ Telephone Number __________________________________ "Notification to the Workers' Compensation Claimant" Per Labor Commission Rule R612-2-22, an injured worker who files a claim for workers' compensation benefits is required, if requested, to provide the name and address of medical providers who have provided any medical treatment for up to the past 10 years. This is your notice that any and all of the medical records within the custody of the medical provider that you have listed may be requested by the party named on this form, as authorized by Rule R612-2-22.* The medical provider is required to release the medical records per the rule, in order for the insurance carrier, self-insured employer, or the Labor Commission to make a determination in your case. *You are required to sign the "Authorization to Release Medical Records" Form 308. Please list all the medical providers for industrial injury first. Please list any other medical providers who have treated you for medical problems within the past _____ years (up to 10 years). ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ ______________________________________Zip____________ Telephone Number_______________________________ Telephone Number_______________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ Telephone Number_______________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ Telephone Number________________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ Telephone Number______________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ Telephone Number_______________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ Telephone Number_______________________________ ______________________________________________________ ______________________________________________________ ______________________________________Zip____________ Telephone Number________________________________ STATE OF UTAH LABOR COMMISSION Division of Adjudication 160 East 300 South 3rd Floor P. O. Box 146615 Salt Lake City, Utah 84114-6615 Phone: (801) 530-6800 Fax: (801) 530-6333 Please attach additional pages, if necessary. *Medical Providers who have treated you related to your reproductive organs or for psychological problems do not have to be listed unless you have made a claim for benefits related to these medical problems. American LegalNet, Inc. www.FormsWorkFlow.com
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