Fill and Sign the Fillable Online Dirweb State Nv Revised D 31 Formdoc

Date: To: Address: Re: Claim No: Date of Injury: Employer: Insurer/TPA: NOTICE OF INTENTION TO CLOSE CLAIM (Pursuant to NRS 616C.235) After a careful and thorough review of your workers' compensation cl aim, it has been determined that all benefits have been paid and your claim will be closed effective seventy (70) days from the date of this notice. Based on the available medical information, the claim will be closed without a Permanent Partial Disability (PPD) evaluation as there is no possibility of a permanent impairment of any kind. Your file reflects that you are not presently undergoing any medical treatment; however, if you are scheduled for future medica l appointments, please advise this office immediately. Nevada Revised Statute (NRS) 616C.390 defines your right to reopen your claim. You must make a written request for reopening and your doctor must submit a repor t relating your problem to the original industrial injury. The report must state that your condition has worsened since the time of claim closure a nd that the condition requires additional medical care. Reopening is not effective prior to the date of your request for reopening unless good cause is shown. Upon such showing by your doctor, th e cost of emergency treatment shall be allowed. If you disagree with the above determination, you do have the right to appeal. If your appeal concerns "accident benefits" (medical treatment or supplies) and your insurer has contract ed with an organization for managed care, complete the bottom portion of this notice and send it to your insurer no later th an fourteen (14) days after the date of this notice. If your appeal concerns " compensation benefits," or if no organization for managed care is involved in your claim, complete the bottom portion of this notice and send it to the State of Neva da, Department of Administration, Hearings Division. Your appeal must be filed within seventy (70) days after the date on which the notice of the insurer's final determination was mailed . Department of Administration OR Department of Administration Hearings Division Hearings Division 1050 E. William Street, Ste. 400 2200 S. Rancho Drive, Suite 210 Carson City, NV 89710 Las Vegas, NV 89102 (775) 687-8440 (702) 486-2525 R easo n f o r a p peal: S ig natu re D ate Retain a copy of this notice for your records. c.: Enclosure D-31 (rev. 10/10)