NOTICE OF SUSPENSION OF MEDICAL BENEFITS State Form 54217 (3-10) INDIANA WORKER’S COMPENSATION BOARD 402 W Washington Street, Room W196 Indianapolis, IN 46204 * PRIVACY NOTICE: This agency is requesting disclosure of your Social Security number in accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing. Pursuant to IC 22-3-3-4(c) or 22-3-3-6(a), NOTICE is hereby given that the employer intends to suspend all benefits for a compensable injury under the Indiana Worker’s Compensation Act because of employee’s refusal to accept medical services and/or supplies prescribed by the authorized treating physician and provided by employer. EMPLOYER AND CARRIER INFORMATION Name of employer Federal Identification number Address (number and street, city, state, and ZIP code) Name of Insurance Carrier / Third Party Administrator Claim number of insurer Address (number and street, city, state, and ZIP code) ADJUSTER / ATTORNEY INFORMATION Name of adjuster / attorney (typed or printed) Address (number and street, city, state, and ZIP code) Telephone number ( ) Fax number ( E-mail address ) Date signed (month, day, year) Signature of adjuster / attorney EMPLOYEE INFORMATION According to IC 22-3-3-4(c) or 22-3-3-6(a), injured workers shall not receive temporary total or partial disability payments and/or permanent partial impairment payments, reimbursement for unauthorized medical care, nor are they entitled to have a case heard, until they agree to follow the treatment plan set by the treating physician. Name of employee Social Security number * Address (number and street, city, state, and ZIP code) Telephone number ( Date suspension initiated (month, day, year) ) Date of injury (month, day, year) Reason medical benefits are being suspended: Actions required to have medical benefits reinstated:: Signature of employee acknowledging receipt: Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com