Utah > Workers Compensation
Medical Treatment Provider List 307 - Utah
| Medical Treatment Provider List Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 307 I MEDICAL TREATMENT PROVIDER LIST PLEASE PRINT OR TYPE Claimant Name ________________________ Address ______________________________ ______________________________ Telephone ____________________________ Social Security Number ________________________ Date of Injury ________________________________ Employer ___________________________________ "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 (15 years if Permanent Total claim or in Adjudication). 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 I. Please list all the medical providers for industrial injury first. Please list any other medical providers who have treated you for any medical problems within the past 10 years (up to 15 years). ________________________________________ ________________________________________ ________________________________________ Telephone Number ________________________ ________________________________________ ________________________________________ ________________________________________ Telephone Number ________________________ ________________________________________ ________________________________________ ________________________________________ Telephone Number ________________________ Please attach additional pages, if necessary. _______________________________________ _______________________________________ _______________________________________ Telephone Number _______________________ _______________________________________ _______________________________________ _______________________________________ Telephone Number _______________________ _______________________________________ _______________________________________ _______________________________________ Telephone Number _______________________ Name of Party Requesting the Medical Records ______________________________________________ Address ________________________________________________________________________________ Telephone Number _______________________ Fax Number __________________________________ Relationship to claim ____________________________________________ 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 those medical problems. Please forward this form to the Requesting Party at the above listed address/fax number. Official Form 307 I 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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