Fill and Sign the Original Notice Petition and Form

(TYPE OR PRINT) 14-0011 (11/06) FORM 100C BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER Claimant __________________________ VS. Employer___________________________________ Street______________________________________ City_________________State_______Zip_________ Insurance Carrier____________________________ Street______________________________________ City__________________State________Zip_______ File Number ________________________ ORIGINAL NOTICE, PETITION, AND ANSWER CONCERNING APPLICATION FOR ALTERNATE MEDICAL CARE (IOWA CODE SECTION 85.27) (Rule 876 IAC 4.48) Injury Date_____________________________________ Body Part(s) Injured ORIGINAL NOTICE To the Above-Named Employer: You are notifi ed that an action has been commenced before the Iowa Workers' Compensation Commissioner seeking relief as set forth in the petition below. DUE TO THE TIME CONSTRAINTS, IT IS NOT NECESSARY TO FILE AN ANSWER. If no answer is filed, a response will be required at a hearing. If it is disputed that the employer is liable on this claim, this case will be dismissed without prejudice. NOTE: You should promptly advise your workers’ compensation insurance carrier and attorney that you have received this notic e. PETITION (To Be Completed By Claimant) In support of this claim for alternate medical care, claimant states: 1. Claimant sustained injury arising out of and in the course of employment with the employer on (Date)__________ 2. The injury occurred at (City)___________________________, (County)__________________, and (State)____________. 3 The injury has caused need for medical treatment. 4. The treatment offered by employer is not reasonably suited to treat the injury without undue inconvenience to claimant. 5. Claimant is dissatisfied with the care provided and has communicated that dissatisfaction to employer. Reason for dissatisfaction and relief sought: 6. A hearing is requested by telephone conference call; or. in person to be held in Des Moines, Iowa (If neither party requests an in-person hearing, a telephone hearing will be scheduled.) 7. Employer does not dispute liability on this claim. 8. The provisions of Rule 876 IAC 4.48 are invoked. (If Represented by Attorney) _____________________________________ __________ Attorney______________________________________________ _______ (Claimant’s Signature) Claimant’s Pho ne No. ( ) _____________ _____ Street ___________________________________________________________ (include area code) Date signed:________________________________________________ City______________________________State____________Zip_____________ ____________________________________________________________ _______________________________________________________________ Email Address of Attorney Attorney Signature Fax (Include Area Code ___________________________________________ Phone (Include Area Code)____________________________________________ Date Signed: _____ _______________________________________________ THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11 _______________________________________vs.____________________________________ File No. _____________________ Claimant Employer PROOF OF SERVICE On the __________________ day of ________________________, ___________, I mailed a copy of the foregoing original notice and petition by certified mail, return receipt requested, to the employer’s last known address which is:__________________________ ________________________________________________________________________\ ___________________________________ I CERTIFY under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. Date_________________________ Signature_____________________________________________________________________ ANSWER (Employer/Insurance Carrier must answer on this form) 1. A hearing is requested. by telephone conference call; or in person to be held in Des Moines, Iowa, (If neither party requests an in-person hearing, a telephone hearing will be scheduled.) 2. (Check if applicable) Employer denies paragraph 7 of the Petition and disputes liability of this claim. Employer____________________________________ Street______________________________________ City___________________State___________Zip___ Phone (Include Area Code)____________________ Insurer_______________________________________ Street________________________________________ City____________________State___________Zip____ Phone (Include Area Code)_______________________ _____________________________________________ Signature of Person Answering Name:______________________________________ Title:_______________________________________ Date signed: ________________________________ (If Represented by Attorney) Attorney_____________________________________ Street______________________________________ City_____________________State________Zip___ Phone (Include Area Code)___________________ Date Signed: ________________________________ INSTRUCTIONS - BOTH PARTIES MUST USE THIS FORM To Claimant: 1. Alternate medical care is the only issue that can be considered under this procedure. 2. Complete lines 1, 2, 5, and 6 of the petition. Attach the claimant’s confidential information sheet. 3. Deliver a completed copy of this form to the employer by certified mail, return receipt requested or by personal service as in civil actions (rule 876 IAC 4.7) and mail a copy to the employer’s attorney of record for this file if known (rule 876 IAC 4.13). 4. Complete the proof of service portion on the original of this form and deliver this entire form with the physician’s report to the Division of Workers' Compensation at 1000 East Grand Avenue, Des Moines, Iowa 50319-0209. To Employer/Insurance Carrier: 1. If you file an answer, serve a copy to the claimant or claimant’s attorney pursuant to rule 876 IAC 4.13. 2. Type or print the name and title of the person answering below the signature line. Generally : 1. This procedure is not available if employer disputes liability on the claim generally. If liability is disputed, this case will be dismissed without prejudice. Disputed cases should be commenced under rule 876 IAC 4.1 14-0 011 (back) (11- 06) (revised to filla ble 2-09) Form 100C