Fill and Sign the Injured Workersif Idaho State Insurance Fund Form

SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041 WORKERS' COMPENSATION COMPLAINT CLAIMANT'S (INJURED WORKER) NAME AND ADDRESSTELEPHONE NUMBER:CLAIMANT'S ATTORNEY'S NAME, ADDRESS, AND TELEPHONE NUMBEREMPLOYER'S NAME AND ADDRESS ( at time of injury)WORKERS' COMPENSATION INSURANCE CARRIER'S (NOT ADJUSTOR'S) NAME AND ADDRESSCLAIMANT'S SOCIAL SECURITY NO.CLAIMANT'S BIRTHDATEDATE OF INJURY OR MANIFESTATION OF OCCUPATIONAL DISEASESTATE AND COUNTY IN WHICH INJURY OCCURREDWHEN INJURED, CLAIMANT WAS EARNING AN AVERAGE WEEKLY WAGEOF: $_______________, PURSUANT TO IDAHO CODE § 72-419DESCRIBE HOW INJURY OR OCCUPATIONAL DISEASE OCCURRED (WHAT HAPPENED)NATURE OF MEDICAL PROBLEMS ALLEGED AS A RESULT OF ACCIDENT OR OCCUPATIONAL DISEASEWHAT WORKERS' COMPENSATION BENEFITS ARE YOU CLAIMING AT THIS TIME?DATE ON WHICH NOTICE OF INJURY WAS GIVEN TO EMPLOYERTO WHOM NOTICE WAS GIVENHOW NOTICE WAS GIVEN:  ORAL  WRITTEN  OTHER, PLEASE SPECIFYISSUE OR ISSUES INVOLVEDDO YOU BELIEVE THIS CLAIM PRESENTS A NEW QUESTION OF LAW OR A COMPLICATED SET OF FACTS?  YES  NO IF SO, PLEASE STATE WHY.NOTICE: COMPLAINTS AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND MUST BE IN ACCORDANCE WITH IDAHO CODE § 72-334 AND FILED ON FORM I.C. 1002IC1001 (Rev. 1/01/2004) (COMPLETE OTHER SIDE) Complaint – Page 1 of 3 Appendix 1 PHYSICIANS WHO TREATED CLAIMANT (NAME AND ADDRESS)WHAT MEDICAL COSTS HAVE YOU INCURRED TO DATE?WHAT MEDICAL COSTS HAS YOUR EMPLOYER PAID, IF ANY? $__________________ WHAT MEDICAL COSTS HAVE YOU PAID, IF ANY? $__________________I AM INTERESTED IN MEDIATING THIS CLAIM, IF THE OTHER PARTIES AGREE.  YES NODATESIGNATURE OF CLAIMANT OR ATTORNEY PLEASE ANSWER THE SET OF QUESTIONS IMMEDIATELY BELOW ONLY IF CLAIM IS MADE FOR DEATH BENEFITS NAME AND SOCIAL SECURITY NUMBER OF PARTY FILING COMPLAINTDATE OF DEATHRELATION TO DECEASED CLAIMANTWAS FILING PARTY DEPENDENT ON DECEASED? YES  NODID FILING PARTY LIVE WITH DECEASED AT TIME OF ACCIDENT?  YES  NO CLAIMANT MUST COMPLETE, SIGN AND DATE THE ATTACHED MEDICAL RELEASE FORM CERTIFICATE OF SERVICE I hereby certify that on the ____ day of __________, 20___, I caused to be served a true and correct copy of the foregoing Complaint upon: EMPLOYER'S NAME AND ADDRESS SURETY'S NAME AND ADDRESS _______________________________________ _____________________________________ _______________________________________ _____________________________________ ____________________________________________________________________________via:A personal service of process via:A personal service of process A regular U.S. Mail A regular U.S. Mail ________________________________________________________SignatureNOTICE: An Employer or Insurance Company served with a Complaint must file an Answer on Form I.C. 1003 with the Industrial Commission within 21 days of the date of service as specified on the certificate of mailing to avoid default. If no answer is filed, a Default Award may be entered!Further information may be obtained from: Industrial Commission, Judicial Division, P.O. Box 83720, Boise, Idaho 83720-0041 (208) 334-6000. (COMPLETE MEDICAL RELEASE FORM ON PAGE 3) Complaint – Page 2 of 3 Patient Name:______________________________Birth Date:_________________________________Address:___________________________________Phone Number:_____________________________SSN or Case Number:________________________ AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION I hereby authorize ___________________________________________ to disclose health information as specified: Provider Name – must be specific for each provider To:_________________________________________________________________________________________ Insurance Company/Third Party Administrator/Self Insured Employer/ISIF, their attorneys or patient’s attorney____________________________________________________________________________________________ Street Address____________________________________________________________________________________________ City StateZip CodePurpose or need for data:___________________________________________________________ (e.g. Worker’s Compensation Claim ) Information to be disclosed: Date(s) of Hospitalization/Care:_____________________ Discharge Summary History & Physical ExamConsultation ReportsOperative ReportsLabPathologyRadiology ReportsEntire RecordOther: Specify_____________________________________________ I understand that the disclosure may include information relating to (check if applicable):AIDS or HIV Psychiatric or Mental Health InformationDrug/Alcohol Abuse InformationI understand that the information to be released may include material that is protected by Federal Law (45 CFR Part 164) and that the information may be subject to redisclosure by the recipient and no longer be protected by the federal regulations. I understand that this authorization may be revoked in writing at any time by notifying the privacy officer, except that revoking the authorization won’t apply to information already released in response to this authorization. I understand that the provider will not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. Unless otherwise revoked, this authorization will expire upon resolution of worker’s compensation claim. Provider, its employees, officers, copy service contractor, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized by me on this form and as outlined in the Notice of Privacy. My signature below authorizes release of all information specified in this authorization. Any questions that I have regarding disclosure may be directed to the privacy officer of the Provider specified above. _____________________________________________________________________________________________Signature of Patient Date_____________________________________________________________________________________________Signature of Legal Representative & Relationship to Patient/Authority to ActDate_____________________________________________________________________________________________Signature of Witness TitleDate Complaint – Page 3 of 3 (Provider Use Only) Medical Record Number:_______________________ D Pick up Copies D Fax Copies #________________ D Mail Copies ID Confirmed by:______________________________