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Agreement That No Impartial Physician Report Is Required 121A - Massachusetts
| Agreement That No Impartial Physician Report Is Required Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 121A The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100, Boston Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia AGREEMENT THAT NO IMPARTIAL PHYSICIAN REPORT IS REQUIRED THIS FORM MUST BE SUBMITTED TO THE ADMINISTRATIVE JUDGE IN A TIMELY FASHION. Please Print or Type EMPLOYEE _______________________________ BOARD NUMBER _____________________ Pursuant to 452 C.M.R. 1.10 the parties make the following agreement under the subsection identified below: (5) (5) (6) (7) ______ ______ ______ ______ The disputed matter concerns a ยง7A and/or death case. Dispute over entitlements of prior disability benefits. Agreement upon partial disability and causal relationship. Agreement that initial liability has not been established. PARTIES: ________________________________ ________________________________ _________________________________ _________________________________ Pursuant to 452 C.M.R. 1.11(1)(d) at the discretion of the administrative judge at the hearing, the parties have been allowed to make the agreements indicated above. ADMINISTRATIVE JUDGE ________________________________________________ ----------------------------------------------- FOR INTERNAL USE ONLY ------------------------------------------Impartial Exam Date _______________ Docketing Unit Impartial Unit Reproduced as needed. Fee Date ______________________ Processed By ________________________________ Date _________________ Processed By ________________________________ Date _________________ Form 121A - Revised 7/2010 American LegalNet, Inc. www.FormsWorkFlow.com
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