Utah > Workers Compensation
Medical Records Copies 302 - Utah
| Medical Records Copies Form. This is a Utah form and can be used in Workers Compensation . |
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Form 302 MEDICAL RECORDS - COPIES PLEASE PRINT OR TYPE Print Form Name of Injured Employee ______________________________Date of Birth _______________________ Address _______________________________________________________________________________ Social Security Number ___________________________ Phone Number _________________________________ Name of Employer ______________________________________________________________________ Name of Industrial Health Care Provider _____________________________________________________ MEDICAL RECORDS NEEDED TO SUBSTANTIATE THE CLAIM OF THE ABOVE INDUSTRIAL INJURY/ILLNESS (Only those checked are being requested) _____ Histories and Physicals _____ Radiological Reports _____ Emergency Room Records _____ Specialized Testing Results _____ Discharge Summaries Date of Injury __________________________ _____ Operative Reports Related to the Industrial Injury/Illness _____ Physician Progress Notes and/or Specialized Reports (Alternatively, a summary of the patient's record may be made available to the claimant at the discretion of the physician.) I have reviewed the above injured employee's claim and certify that the above medical records are needed to substantiate his/her industrial injury/illness. __________________________________ Signature Labor Commission Staff _________________ Date * Per Rule R612-2-22(M), the injured employee is entitled to one copy of the above checked medical records free of charge. Industrial Accidents Division Utah Labor Commission *DO NOT SEND THE RECORDS TO THE LABOR COMMISSION. PLEASE RELEASE THE ABOVE MEDICAL RECORDS AND SEND OR GIVE THE ABOVE MEDICAL RECORDS TO THE INJURED EMPLOYEE. Official Form 302 Revised 3/11 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
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