Form 38911 - Report Of Claim Status / Request For Independent Medical Examination - Worker'S Compensation Board, State Of Indiana
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1PRIVACY NOTICE
REPORT OF CLAIM STATUS /
*This agency is requesting
REQUEST FOR INDEPENDENT MEDICAL EXAMINATION
disc losure of your Social
Security number in accor-
State Form 38911 (R4 / 5-97)
dance with IC 22-3-4-13. This
disclosure is not mandatory
and you will not be penalized
for refusing.
INSTRUCTIONS: Complete appropriate sections of this document and sign in the space below.
CLAIM INFORMATION
Name of employer
Federal I.D. Number
Address of employer
Telephone number
(
)
Name of insurer
Insurer claim number
Date of injury
Address (city, state, ZIP code)
Telephone number
(
)
Telephone number
*Social Security Number
Address of employee
Name of employee
(
)
BENEFIT TERMINATION / DENIAL NOTICE (check appropriate action)
Notice of denial must be made in writing and mailed not later than twenty nine (29) days after the employer's knowledge of the injury
(IC 22-3-3-7). Report compensation payments in the appropriate section below, if applicable.
Return to work
Claim deemed not compensable
Benefit termination (see compensation payments section below)
Refusal to accept medical treatment, services and supplies, provided by or on behalf of your employer, shall bar your compensa-
tion otherwise payable during the period of refusal (IC 22-3-3-4).
Refusal to allow an autopsy shall result in a suspension of all compensation (IC 22-3-3-6).
Refusal to accept employment suitable to your partial disability shall bar any compensation during such refusal unless, in the
opinion of the Worker's Compensation Board of Indiana, such refusal was justified (IC 22-3-3-11).
Other (specify) ____________________________________________________________________________________________
If the employee disagrees with the proposed termination, the employee must give a written notice to the Worker's Compensation
Board and employer within seven (7) days after receipt of this termination notice (IC 22-3-3-7). See Independent Medical
Examination Request section below.
COMPENSATION PAYMENTS
All compensation payments should be reported to the Board on the below prescribed form (IC 22-3-3-7).
No. wks. paid
Paid to: (name)
Total amount paid
Beginning date of payments
Ending date of payments
Employee
$
Dependent
Reason(s) for ending payments
TTD
TPD
PPI
PTD
INDEPENDENT MEDICAL EXAMINATION REQUEST
Employees who disagree with proposed benefit termination must serve a copy of this disagreement notice to the Worker's Compensa-
tion Board and the employer within seven (7) days after receipt of the termination portion of this notice. Please sign below to make
an independent medical examination request. An employee may request an independent medical examination to resolve a medical
issue dispute.
MAIL TO:
Employee disagrees with proposed termination:
Yes
No
W o r k e r ' s C o m p e n s a t i o n B o a r d
Employee requests independent medical examination:
Yes
No
402 W. Washington St.
Rm. W196
Employer requests independent medical examination:
Yes
No
Indianapolis, IN 46204-2753
EMPLOYER CERTIFICATION / RECEIPT OF EMPLOYEE / DEPENDENT
Employer and employee must sign below to certify service or acknowledge receipt of this notice.
Signature of employer
Signature of employee
X
X
Date signed (month, day, year)
By:
Date signed (month, day, year)
By:
U.S. Mail
U.S. Mail
Personal service
Personal service
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