Request For Medical Records (Copies) {302}

Form 302 MEDICAL RECORDS ­ COPIES PLEASE PRINT OR TYPE Name of Injured Employee ________________________________________________________________ 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 records 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 R612-300-10(C), the injured employee is entitled to one copy of the above checked medical records free of charge. However, if the records are requested by an injured workers' attorney, the medical provider may bill the attorney as per Rule R612-300-10(K). 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 10/14 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