Notice Of Claim Acceptance {D-30} | Pdf Fpdf Docx | Nevada

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Notice Of Claim Acceptance {D-30} | Pdf Fpdf Docx | Nevada

Notice Of Claim Acceptance {D-30}

This is a Nevada form that can be used for Workers Comp.

Alternate TextLast updated: 4/9/2019

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<Date> <Addressee> Re: Claim Number: Date of Injury: Employer: Insurer: Claims Administrator/Third-Party Administrator: Body Part(s)/Diagnosis: NOTICE OF CLAIM ACCEPTANCE (Pursuant to NRS 616C.065) Dear > The above referenced claim has been accepted on behalf of (Insert Insurer). Please check the information contained in this notice. If you find any of the information to be incorrect, please notify the claims administrator who is handling this claim. If you disagree with the above determination, you do have the right to appeal by requesting a hearing before a Hearing Officer by completing the enclosed Form D-12a and sending it to the State of Nevada, Department of Administration, Hearings Division. Your appeal must be filed within seventy (70) days after the date on which the notice of this determination was mailed. Department of Administration OR Department of Administration Hearings Division Hearings Division 1050 E. William Street, Ste. 400 2200 S. Rancho Drive, Ste. 210 Carson City, NV 89701 Las Vegas, NV 89102 (775) 687-8440 (702) 486-2525 If you have any questions, please contact > Sincerely, <Claims Adjuster> Enclosure: D-53, D-12a > cc: Please retain a copy for your records D-30 (rev. 10/18) <If established and available, internet address for the website to obtain a list of healthcare providers> American LegalNet, Inc. www.FormsWorkFlow.com

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