Fill and Sign the Request for Additional Medical Information and Medical Release

Request for Additional Medical Information And Medical Release (Pursuant to NRS 616C.177 & 616C.490(4)) Injured Employee's Name: Claim Number: Social Security Number: Injured Employee's Address: Injury/Occupational Disease Date: Date this Notice Printed: Insurer's Name: Employer: Insurer's Address: Employer's Address: Please provide the information requested below, sign and date the form, and return it to your insurer. Your signature on this form also acts as a release to acquire information affecting your claim from other entities. This renews the release you signed on your C-4 form at the time your claim was submitted to your insurer. Failure to fully complete and return this form to your claims agent in a timely manner could affect your benefits or delay the resolution of your claim. Prior History Information Please check the appropriate box below and provide the information requested. … I have no prior conditions, injuries or disabilities of which I am aware, that might affect the disposition of the claim referenced above. (If you checked this box, no further information is needed at this point) … I have a prior condition, injury or disability that could affect the disposition of the claim referenced above. This can include birth defects, prior surgeries, injuries, etc., whether work related or not. (If you checked this box, indicating a pre-existing condition, please explain in detail in the space below. Please attach additional sheets of paper to this form if necessary to fully explain the condition) I certify that the above is true and correct to the best of my knowledge and that I have provided this information in order to obtain the benefits of Nevada’s industrial insurance and occupational diseases acts (NRS 616A to 616D, inclusive or chapter 617 of NRS). I hereby authorize any physician, chiropractor, surgeon, practitioner, or other person, any hospital, including veterans administration or governmental hospital, any medical service organization, any insurance company, or other institution or organization to release to each other, any medical or other information, including benefits paid or payable, pertinent to this injury or disease, except information relative to diagnosis, treatment and/or counseling for aids, psychological conditions, alcohol or controlled substances, for which I must give specific authorization. A photostat of this authorization shall be as valid as the original. ______________________________________________ _________________________________ Signature Date D-36 (Rev. 12/07)