Fill and Sign the Forms West Virginia Offices of the Insurance Commissioner

WEST VIRGINIA WORKERS’ COMPENSATION OFFICE OF JUDGES PSYCHIATRIC OR PSYCHOLOGICAL REPORT CERTIFICATION OF CONFIDENTIALITY Claimant Name: ___________________Claim Number: ___________________SSN : ___________________________DOI / DLE: ______________________Pursuant to W.Va. Code §23-1-13(f) a treating or evaluating psychiatrist or clinical doctoral level psychologist has directed that a psychiatric or psychological report be withheld from the claimant because it has been certified that exposure to the contents of the full report is likely to cause serious harm to the claimant or is likely to cause the claimant to pose a serious threat of harm to a third party. As further required by §23-1- 13(f), a summary of the report has been prepared which may be provided to the claimant upon his or her request. Enclosed with this form are both the full report and the summary.Report Author: _________________ Date of Report: ___________ # of Pages _____Summary Author:________________ Date of Summary:_________ # of Pages ______Re: ___ __ protest to the Division’s Order of __ __ (claimant’s/employer’s) (date)I certify that the requirements of W.Va. Code §23-1-13(f) have been complied with concerning the attached reports. Date: _____________________ Signature:_________________________________***This form is to be used in addition to your regular correspondence letter to submit confidential psychiatric or psychological reports and summaries thereof to the Office of Judges. Please attach both the report and the summary to this form. This form will assist the Office of Judges in the indexing of legal documents into the Bureau’s Electronic Document Management System (EDMS). If you have any questions concerning the use of this form, please direct your inquiries to our general inquiry unit at 558-0852***