WORKERS' COMPENSATION COMMISSION DEPENDENT'S CLAIM FOR DEATH BENEFITS Instructions: This form must be completed in its entirety and signed by the filing party. 1. Name of Deceased: 2. First Middle Last 3. Deceased’s Date of Birth (mm/dd/yyyy): Deceased’s Social Security Number 4. Filing Party: Name: Mailing Address: City State ZIP Code: Telephone Number: ( ) 5. Filing Party’s Relationship to Deceased (spouse, child, parent, other): 6. I am authorized to file this claim on behalf of the dependent claimant(s) because: 7. Date of Injury/occupational disease disablement (mm/dd/yyyy) : 8. Location Where Accident/Injury Occurred: Complete Address: City ZIP Code: State 9. Describe how the accidental injury 10. Member of the body that was injured: 11. Date of Death (mm/dd/yyyy): or occupational disease occurred: 12. Cause of Death: 13. Deceased’s Employer: Name: Complete Address: City Telephone Number: ( State ZIP Code: ) 14. Deceased’s Gross Wages per Week (Average Weekly Wage): $ 15. List All Deceased's Known Dependents (including filing party): Name and Address (a) Social Security Number Date of Birth Relationship to Deceased Type of Dependency Wholly Partially (b) (c) (d) I hereby make claim as, or on behalf of, a Dependent of the above-named Deceased employee and certifying that the information contained in herein is accurate to the best of my knowledge, information and belief. Signature of Person Filing this Claim Date 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC C35 (10/05/07) Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com DEPENDENT'S CLAIM FOR DEATH BENEFITS AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Pursuant to Labor and Employment Article, §§ 9-710, and 9-711, Annotated Code of Maryland, and COMAR 14.09.01.06, this authorization must be signed and filed with the Workers’ Compensation Commission of Maryland in conjunction with any claim amendment form. A. Person Covered by Authorization This document authorizes the disclosure of protected health information regarding: Name of Deceased Employee B. Date of Birth Purpose of Disclosure This document authorizes the disclosure of protected health information for the purpose of processing, adjudicating and resolving workers’ compensation claims. C. Entities Authorized to Make Disclosure This document authorizes any health plan, physician, health care professional, dentist, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to the deceased employee to disclose the deceased employee’s protected health information consistent with this directive. D. Entities Authorized to Receive Protected Health Information This document authorizes the disclosure of the deceased employee’s protected health information to the following entities and their agents: the dependent claimant’s or the deceased employee’s attorney, the deceased employee’s employer, the employer’s workers’ compensation insurer or any agent thereof. E. Information to be Disclosed This document authorizes the entities listed in C to disclose protected health information that is relevant to: 1. The member of the body that was injured as indicated on the claim application form. 2. The description of how the accidental injury occurred as indicated on the claim application form. 3. The description of how the occupational disease occurred as indicated on the claim application form. The protected health information that may be disclosed includes, but is not limited to: history, findings, office and patient charts, files, examination and progress notes, and physical evidence. F. I understand that I may revoke this authorization by giving written notice to all parties to this claim for workers’ compensation death benefits, except to the extent that this authorization has already been acted on prior to receipt of my revocation. I understand that the information disclosed by this authorization may be subject to re-disclosure by the recipient to a medical manager, health care professional or registered rehabilitation practitioner, and others consistent with state and federal law. By signing this form, I am authorizing the disclosure of the deceased employee’s protected health information. This authorization is valid for one year from the date the Dependent’s Claim for Death Benefits form is filed. Signature of Dependent Claimant or Authorized Representative Date Statement of Authorization: I am authorized to sign or act on behalf of the dependent claimant(s) because: A photocopy, facsimile or electronic transmission of this signed authorization form is valid. MD WCC C35 (10/05/07) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com IMPORTANT: It is the Dependent's or the Authorized Representative's responsibility to maintain a current mailing address with the Commission. The Commission Claim Number should be included on all correspondence. Disclosure Pursuant to COMAR 01.01.1983.18 1. The personal information requested on this form is intended to be used in processing your claim under the Maryland workers’ compensation laws. 2. Failure to provide the information requested may result in your claim being rejected or a delay in the processing of your claim. 3. You may have a right to inspect, amend and correct the information provided on this form pursuant to State Government Article, §10624, Maryland Code Annotated. 4. This form will be made part of your claim file. Portions of your claim file may be subject to public inspection. 5. The information contained on this form is routinely shared with State, Federal or local agencies. Death Benefits Claim Filing Instructions To file a claim for death benefits as a dependent or on behalf of a dependent, this form must be completed, signed and filed. The Commission does not accept any claim forms, documents or claim-related information via facsimile (FAX) or email. 1. All entries MUST be completed in Adobe Reader when enabled, typed or hand printed as clearly as possible in DARK OR BLACK INK. 2. Provide all requested information. 3. Dates must be filled in MM/DD/YYYY (month-day-year) format. 4. When information is not available, zeros MUST be entered. For example, Social Security Number: 000000000 (9 zeros). 5. Entries MUST NOT exceed the length of the space. abbreviate WITHOUT punctuation. When the information is longer than the space allows, 6. IF THERE IS NOT ENOUGH SPACE ON THE CLAIM FORM, PLEASE ATTACH ADDITIONAL PAGES WITH A PAPER CLIP. PLEASE NUMBER THE ITEMS THAT ARE BEING ADDED. 7. DO NOT cross out, staple, tape or use correction fluid or tape (White-Out) on the form. 8. A claim form that does not contain the filing party’s name and address, the dependent claimant(s)’ name and address, the deceased employee's name and employer, date of accident or occupational disease, a description of how the accidental injury or occupational disease occurred, or sufficient information to process the claim may be rejected and returned to the dependent or authorized representative. 9. Sign and date the Dependent’s Claim for Death Benefits. 10. Read, sign and date the Dependent’s Claim for Death Benefits Authorization for Disclosure of Health Information. A CLAIM FORM THAT DOES NOT CONTAIN A SIGNED AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION WILL BE REJECTED AND RETURNED TO THE DEPENDENT OR AUTHORIZED REPRESENTATIVE. 11. ATTACH: (1) a certified copy of the certificate of death for the deceased employee; (2) a certified copy of the certificate of marriage for the dependent and deceased employee, if the dependent is the surviving spouse of the employee; and (3) a certified copy of the certificate of birth for the dependent, if the dependent is the surviving child of the deceased employee. 12. If you are making a claim for funeral benefits attach a notarized Certification of Funeral Benefits form (WCC C-18). The Certification of Funeral Benefits form must: (1) be signed by the provider of funeral services or mortician; (2) include an attached itemized statement of the services performed and corresponding costs; (3) be signed by the person authorizing the burial or other services; (4) be notarized; and (5) include the name of the deceased employee. FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN UNNECESSARY DELAY OR RETURN FOR CORRECTION AND RESUBMISSION OF THE CLAIM FORM. 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC C35 (10/05/07) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com