Fill and Sign the Records Request Form Please Allow Up to 5 7 Business

Form 310 REQUEST/APPEAL FOR ADDITIONAL Claimant Name _________________________ Date of Birth _____________________________ Address _______________________________ Social Security Number ____________________ ______________________________________ Date of Injury ____________________________ Telephone Number ______________________ Employer ______________________________ Official Form 310 Revised 2/09 State of Utah ● Labor Commission ● Division of Industrial Accidents 160 East 300 South ● P.O. Box 146610 ● Salt Lake City, UT 84114-6610 ● Telephone: (801) 530-6800 Fax: (801) 530-6804 ● Toll Free: (800) 530-5090 ● www.laborcommission.utah.gov _______ The Insurance Carrier is requesting a review by the Industrial Accidents Division as to the relevance of the additional requested information. (A summary of the need for the additional information must accompany this form.) Determination: ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ Reason for Determination: ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ Unable to make a determination for the following reason(s): ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ ________________________________________________________________________\ _____________ If unable to make a determination, the insurance carri er will have 15 days from the date of the signed determination in which to submit additional information for consideration. Absent any additional information the request for additional medical information is denie d. Any determination made the Division of Industrial Accidents must be appealed to the Ad judication Division within 30 days from the date of the determination or the determination becomes final. ___________________________________________ ______________________________ Signature of Staff Person Making Determination Date