Fill and Sign the Copy Request Form Okgov

OKLAHOMA WORKERS’ COMPENSATION COMMISSION C O P Y R E Q U E S T F O R M FOR COMMISSION USE ONLY SUBMIT REQUEST FORM TO Oklahoma Workers’ Compensation Commission ATTENTION: Copy Requests 1915 North Stiles Ste 231 Oklahoma City, OK 73105 - 4918 COPIES TO BE RETURNED TO Company Name: ________________________________ ______ Attention: _____________________________ Telephone: ( _____ ) _______________ Address: ________________________________ ______________________________ City/State/Zip: ________________________________ ______________________________ FEE FOR FILES PULLED PAID ☐ EXEMPT ☐ FOR EACH COMMISSION FILE NUMBER YOU MUST : 1. Use a Separate Copy Request Form, and 2. Complete and Sign Part I of this form, if applicable, OR if not applicable, Complete and Sign Part II of this form and Include a $1 Search Fee. 1 INQUIRIES Records Department . . . (405) 522 - 8695 or In - State Toll Free (855) 291 - 3612 Claimant’s Name Date of Injury Commission File No. ☐ CC - FORM A Claimant’s Application for Change of Physician ☐ ORDER Entered on ______ /______/ ______ ☐ CC - FORM 3 Employee’s First Notice of Claim for Compensation ☐ ALL ORDERS ☐ CC - FORM 3A Claimant’s First Notice of Death & Claim for Compensation ☐ ENTRIES OF APPEARANCE ☐ SUBSTITUTION OF ATTORNEY ☐ ATTORNEY WITHDRAWALS ☐ CC - FORM 3B Employee’s First Notice of Occupational Disease & Claim for Compensation ☐ ALL MEDICAL REPORTS ☐ CC - FORM 3F Employee’s Notice of Claim for Benefits from the Multiple Injury Trust Fund ☐ MFDR FORM 19 Provider Request for Medical Fee Dispute Resolution ☐ CC - FORM 9 Request for Hearing ☐ WITH ATTACHMENTS ☐ CC - FORM 20 Proof of Loss (Death Claim) ☐ CC - FORM 10 Answer & Notice of Contested issues ☐ WITH ATTACHMENTS ☐ ENTIRE FILE Files May Contain Duplicate Documents . . . BILLING IS FOR ALL COPIES, INCLUDING DUPLICATES ☐ CC - FORM 13 Request for Prehearing Conference ☐ OTHER (Specify) ☐ Settlement Agreement (Joint Petition) ☐ WITH ATTACHMENTS PART I. STATEMENT OF EXEMPTION: By signing below, I affirm that I meet the requirements of an exemption from the written request and Search Fee requirements of Title 85A O.S. Section 120, as indicated below, and that the information sought is not requested for any non - exe mpt purpose; provided, however, an employer or personnel service company claiming EXEMPTION #6 ALSO MUST COMPLETE PART II OF THIS FORM. Please circle the number of the exemption that applies: EXEMPTIONS 1. Requests made by a public officer or public employee in the performance of his/her duties on behalf of a governmental entity, or as may be allowed by law; 2. Requests made by an insurer, self - insured employer, third - party claims administrator, or a legal representative thereof, when ne cessary to process or defend a workers’ compensation claim; 3. Requests made by a worker or worker’s representative for the worker’s claim information; 4. Disclosures made for educational or research purposes, in such a manner that the disclosed information cannot be used to iden tif y any worker who is the subject of a claim; 5. Requests made by a health care or rehabilitation provider, or legal representative thereof, when necessary to process payment fo r services rendered to a worker; 6. Requests made by an employer or personnel service company where the worker executes a written authorization permitting the se arc h and designating the employer or personnel service company as the worker’s representative for that purpose. (The written authorization must be su bmi tted with this form.) Your Signature: ____________________________________________________Printed Name: _____________________________________________ ___ ______ PART II. COMPLETE THIS IF EXEMPTION #6 (ABOVE) IS CLAIMED OR IF NONE OF THE OTHER EXEMPTIONS LISTED ABOVE APPLY: By signing below, I declare under PENALTY OF PERJURY that the information sought is not for a purpose in violation of any sta te or federal law. I understand I am required by law to disclose the person for whom this search request is being made, if different from myself. This search is bei ng made for: (Name and address of person for whom this search is being made, IF OTHER THAN THE UNDERSIGNED. Please PRINT.) Name _______________________________________________________ Full Address ___________________________________________________ ___ ______ Your Signature: ___________________________________________________ Printed Name: _____________________________________________ ___ ________ Telephone No: ( ______) _____________ Address: _________________________________________ City: _____________________ Stat e: _____ Zip: ______ NOTE ☐ ☐ Please Return A Copy Of This Copy Request Form And Invoice With Your Check Made Payable To The Workers’ Compensat ion Commission Invoice No. ________________________________ Invoice Date: ____________________________ ______________ COPIES @ $1.00 per copy (85 A O.S., §119) = $ ________________________ Total amount due: $ ____________________ POSTAGE = $ _________________________ Rev. 3 - 13 - 17 1 NOTE: BY LAW, THE $1 SEARCH FEE, IF APPLICABLE, MUST ACCOMPANY THE COPY REQUEST WHEN MADE.