SELF-INSURED EMPLOYERS' MEDICAL ONLY CLAIM CLOSURE ORDER AND NOTICE Claim Claimant Date of Injury UBI Number Mailing Date Type MO Physician This order constitutes notification that your claim is being closed with such medical benefits and temporary disability compensation as provided to date and with such award for permanent partial disability, if any, as set forth below, and with the condition that you have returned to work with the self-insured employer. If for any reason you disagree with the conditions or duration of your return to work or the medical benefits, temporary disability compensation provided, or permanent partial disability that has been awarded, you must protest in writing to the Department of Labor and Industries, Self-Insurance Section, PO Box 44892, Olympia WA 98504-4892 within sixty days of the date you receive this order. If you do not protest this order to the Department, this order will become final. This claim is closed with medical benefits only effective for time loss or permanent partial disability. without award (Name of Self-Insured Employer) is not required to pay for medical services or treatment rendered after the date of closure. By For (Name of Self-Insured Employer/Third Party Administrator) Address City Phone F207-020-111 Self-Insured Employers' Medical Only Claim Closure Order and Notice 08-2013 American LegalNet, Inc. www.FormsWorkFlow.com
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