Employees Claim For Post-Lump Sum Medical Mediation {110A}

The Commonwealth of Massachusetts Department of Industrial Accidents Department 110 - A Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7306 Outside Mass. www.mass.gov/dia POST - LUMP SUM MEDICAL MEDIATION FOR USE BY EMPLOYEES SEEKING POST - LUMP SUM MEDICAL MEDIATION ONLY. FORM 110 - A Form 110 - A - 7/2019 - Reproduce as needed. 3. Home Telephone No.: 5. Home Address (No., Street, City, State & Zip Code): - mail address (if available): (NOT LOCAL AGENT/ADMINISTRATOR) : 11. DATE OF INJURY (mm/dd/yyyy ): 14. FIRST day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): E M P L O Y E E 2. Social Security number*: 4. Date of Birth: E M P L O Y E R I N J U R Y B E N E F I T S C L A I M E D 15. FIFTH day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 18. Last Treatment (mm/dd/yyyy): 20. Date (mm/dd/yyyy): 21. ): 22. Date (mm/dd/yyyy): *Disclosure of Social Security number is voluntary. It will aid in the processing of your claim. **Representation by an attorney is not required. 17. Name and Address of Treating Physician: - mail address (Required): DIA Board # (If Known): 16. REQUIRED: Please provide a written explanation as to why the employee is seeking medical mediation. Prescription Attached Medical Note/Report 12. L/S Date (mm/dd/yyyy): REQUIRED : Please check all boxes that apply: American LegalNet, Inc. www.FormsWorkFlow.com