State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION P.O. Box 381 Trenton, NJ 08625-0381 r. 10/01/09 MOTION FOR EMERGENT MEDICAL TREATMENT Pursuant to N.J.S.A. 34:15-15.3 ADDRESS vs ADDRESS TELEPHONE NUMBER (AREA CODE) APPEARING ADDRESS NAME ADDRESS INSURANCE CARRIER RESPONDENT NAME ATTORNEY FOR RESPONDENT Vicinage: NAME ATTORNEY FOR PETITIONER PETITIONER NAME Case No. : NAME SELF-INSURED UNINSURED ADDRESS CLAIM NUMBER TELEPHONE NUMBER (AREA CODE) APPEARING PLEASE TAKE NOTICE that Petitioner seeks emergent medical care pursuant to N.J.S.A. 34:15-15.3. Attached or enclosed are the required supporting documents: A copy of the claim petition and, if received, the answer. A statement by the petitioner or the petitioner’s attorney of the dates and to whom specific requests for authorized medical care were made. A statement by a physician that includes petitioner’s need of emergent medical care, a delay in treatment will result in irreparable harm or damage to the petitioner and the specific nature of the irreparable harm or damage. All relevant medical records in the possession of the petitioner. PETITIONER verifies that service of this motion and supporting materials has been made (check one): If an answer has been filed, by fax and certified mail return receipt on respondent’s attorney. If no answer has been filed, on the petitioner’s employer by personal service or by fax and by certified mail return receipt and if insured by fax and certified mail on the employer’s insurance company contact person (listed on Division’s website). If employer is uninsured, on the Uninsured Employer’s Fund by fax and certified mail return receipt. The personal service, fax service or the date of certified mailing whichever is later shall be considered the date of service. Respondent shall file an answer to the motion within 5 calendar days from the date of service and may have an examination of petitioner conducted within 15 calendar days from the date of service. American LegalNet, Inc. www.FormsWorkFlow.com The following additional information is required for motion scheduling when an answer to the Claim Petition has not been filed: Respondent Telephone Number ________________ Fax (If known) ________________ Insurance Contact Person ________________ Telephone Number ________________ Fax __________________ Motions for Emergent Medical Care must be filed in the District Office (vicinage) the claim petition has been assigned or will be assigned. See N.J.A.C. 12:235-3.1. If no claim petition has been filed one must be filed simultaneously in the Trenton Central Office, Division of Workers’ Compensation, P.O. Box 381, Trenton, NJ 08625. ______________________________________________ Dated: ___________________ ATTORNEY FOR PETITIONER American LegalNet, Inc. www.FormsWorkFlow.com