Form 100c -Original Notice And Petition For Medical Care
ADVERTISEMENT
1
2(TYPE OR PRINT)
14-0011 (5/04)
BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER
FORM 100C
__________________________
Claimant
________________________
File Number
Street______________________________________
ORIGINAL NOTICE, PETITION, AND
City_________________State_______Zip_________
ANSWER CONCERNING APPLICATION FOR
ALTERNATE MEDICAL CARE
VS.
Employer___________________________________
(IOWA CODE SECTION 85.27)
Street______________________________________
(Rule 876 IAC 4.48)
City_________________State_______Zip_________
Claimant’s
Insurance Carrier____________________________
Soc. Sec. No.______________________________________
Street______________________________________
Injury Date_________________________________________
City__________________State________Zip_______
Body Part(s) Injured
ORIGINAL NOTICE
To the Above-Named Employer:
You are notified 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 notice.
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.
__________________________________________,
(Claimant’s Signature)
Phone No. (
) __________________________
(include area code)
Date signed:______________________________________________
(If Represented by Attorney)
Attorney_______________________________________________________________
Street__________________________________________________________________
City______________________________State____________Zip__________________
_____________________________________________________________
Phone (Include Area Code)_______________________________________________
Signature of Attorney.
Date Signed: __________________________________
THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 100 - Original Notice And Petition Before The Iowa Workers' Compensation Commissioner - 2004
Legal
Form 100a 14-0007 - Original Notice And Petition, Answer And Order Concerning Independent Medical Examination 2014
Legal
Related Categories
Parent category: Legal