Kansas > Workers Compensation
Application For Post Award Medical K-WC E-4 - Kansas
| Application For Post Award Medical Form. This is a Kansas form and can be used in Workers Compensation . |
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KANSAS DEPARTMENT OF LABOR www.dol.ks.gov DO NOT WRITE IN THIS SPACE APPLICATION FOR POST AWARD MEDICAL K-WC E-4 (Rev. 6-12) Docket number (required): ____________________________________ Phone: ____________________________________________________ Employee: _________________________________________________ First Middle Last Email: ___________________________________________________ Employer: _________________________________________________ Employee applies for post award medical treatment authorized by the decision entered on_______________________________________ (Date of award or order) 1. State the nature of medical care sought: _____________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ 2. The parties shall meet and confer prior to the scheduled hearing. 3. If the party is represented by an attorney, this form shall be signed by at least one attorney of record as required by K.S.A. 44-536a(a). 4. Are you interested in going through the Workers Compensation mediation process? YES NO Applicant signature: ___________________________________________________________________ Date: _______________________ Address: ________________________________________________________________________________________________________ DO NOT WRITE IN THIS SPACE Attorney signature:_______________________________________ Printed name:___________________________________________ Street: ________________________________________________ City: __________________________ State: ______ ZIP: __________ Email:_________________________________________________ (for purposes of hearing notices) Phone: ________________________________________________ Kansas Supreme Court number: ____________________________ The mandatory requirement that Social Security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number. Federal Privacy Act Disclosure Section 7(a)(2)(B) DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000 · Fax: (785) 296-8580 American LegalNet, Inc. www.FormsWorkFlow.com
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