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Self Insured Employers Medical Only Claim Closure Order And Notice F207-020-111 - Washington
| Self Insured Employers Medical Only Claim Closure Order And Notice Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
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SELF INSURED EMPLOYERS MEDICAL ONLY CLAIM CLOSURE ORDER AND NOTICE CLAIM DATE OF INJURY UBI NUMBER MAILING DATE TYPE MO CLAIMANT PHYSICIAN THIS ORDER CONSTITUTES NOTIFICATION THAT YOUR CLAIM IS BEING CLOSED WITH SUCH MEDICAL BENEFITS AND TEMPORARY DISABILITY COMPENSATION AS PROVIDED TO DATE AND WITH SUCH AWARD FOR PERMANENT PARTIAL DISABILITY, IF ANY, AS SET FORTH B ELOW, AND WITH THE CONDITION THAT YOU HAVE RETURNED TO WORK WITH THE SELF-INSURED EMPLOYER. IF FOR ANY REASON YOU DISAGREE WITH THE CONDITIONS OR DURATION OF YOUR RETURN TO WORK OR THE ME DICAL BENEFITS, TEMPORARY DISABILITY COMPENSATION PROVIDED, OR PERMANE NT PARTIAL DISABILITY THAT HAS BEEN AWARDED, YOU MUST PROTEST IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES, SELF-INSURANC E SECTION, PO BOX 44892, OLYMPIA WA 98504-4892 WITHIN SIXTY DAYS OF THE DATE YOU RECEIVE THIS ORDER. IF YOU DO NOT PROTEST THIS O RDER TO THE DEPARTMENT, THIS ORDER WILL BECOME FINAL. THIS CLAIM IS CLOSED WITH MEDICA L BENEFITS ONLY EFFECTIVE WITHOUT AWARD FOR TIME LOSS OR PERMANENT PARTIAL DISABILITY NAME OF SELF-INSURED EMPLOYER IS NOT REQUIRED TO PAY FOR MEDICAL SERVICES OR TREATMENT RENDERED AFTER THE DATE OF CLOSURE. BY FOR (NAME OF SELF-INSURED EMPLOYER) ADDRESS CITY PHONE ( ) F207-020-111 medical only claim closure
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