Fill and Sign the Occupational Disease Claim Report Nevada Form

State of Nevada Department of Business and Industry Division of Industrial Relations OCCUPATIONAL DISEASE CLAIM REPORT (NRS 617.357) Submit within 30 days of acceptance/denial and any changes to the claim – PART 1 Submit within 30 days of appeal, closure, reopening, or confirmed diagnosis – PARTS 1 & 2 PART 1 Insurer Name:       Insurer FEIN:       Insurer Certificate Number:       Claim Number:       Claimant’s Employer:       Submitted by:       Company:       Insurer TPA Address:       City:       State:       Zip:       Telephone:       Email:       Date of Injury:       Date Claim (C-4) Received by Insurer/TPA:       Claim Disposition: Accepted Denied Date Accepted/Denied:       Reason for Denial: 1-Pending medical investigation 2-Negative test/no exposure 3- Not in course/scope 4-Not compensable/no disease 5-Late reporting 6-Failure to correct predisposing condition 7-Misc (duplicate claim, wrong insurer/uninsured, etc) Estimated Medical Costs of Claim: $       Description of Claim:       CLAIMANT (Choose one) & CLAIM ACCEPTED/DENIED PURSUANT TO NRS (Choose one) : FIREFIGHTER POLICE OFFICER (PEACE OFFICERS PER NRS 289.010 INCLUDED ) NRS 617.453 C ANCER NRS 617.455 LUNG DISEASE NRS 617.455 LUNG DISEASE NRS 617.457 HEART DISEASE NRS 617.457 HEART DISEASE NRS 617.481 CERTAIN CONTAGIOUS DISEASES NRS 617.481 CERTAIN CONTAGIOUS DISEASES NRS 617.485 HEPATITIS NRS 617.485 HEPATITIS NRS 617.487 HEPATITIS ARSON INVESTIGATOR EMERGENCY MEDICAL ATTENDANT NRS 617.455 LUNG DISEASE NRS 617.481 CERTAIN CONTAGIOUS DISEASES NRS 617.457 HEART DISEASE NRS 617.485 HEPATITIS NRS 617.481 CERTAIN CONTAGIOUS DISEASES PART 2 INITIAL APPEAL OF: C LAIM D ENIAL C LAIM A CCEPTANCE Appealed by: Claimant/Dependent/Representative Employer/Insurer Date Appeal Filed:       ` Hearing Date:       Decision: Affirmed Reversed Remanded Modified Dismissed Stip (Explain):       Decision Date:       Decision by: Hearing Officer Appeals Officer SUBSEQUENT APPEAL OF DECISION BY: HO AO DC Appealed by: Claimant/Dependent/Representative Employer/Insurer Date Appeal Filed:       Hearing Date:       Decision: Affirmed Reversed Remanded Modified Dismissed Stip (Explain):       Decision Date:       Decision by: Appeals Officer District Court Supreme Court Diagnosis Confirmed: YES NO Initial Claim Closure Date:       Date Claim Reopened (if applicable):       Subsequent Claim Closure Date (if applicable):       OD-8 (1/14)