Form 307 6/2005 STATE OF UTAH – LABOR COMMISSION Division of Industrial Accidents 160 East 300 South – 3rd Floor P. O. Box 146610 Salt Lake City, Utah 84114-6610 Phone: (801) 530-6800 Fax: (801) 530-6804 MEDICAL TREATMENT PROVIDER LIST Claimant Name _____________________________ Address ___________________________________ ___________________________________ Telephone Number __________________________ Social Security Number ____________________ Date of Injury ____________________________ Employer _______________________________ “Notification to the Workers’ Compensation Claimant” Per Labor Commission Rule R612-2-22, an injured worker who files a claim for workers’ compensation benefits is required, if requested, to provide the name and address of medical providers who have provided any medical treatment for up to the past 10 years (15 years if Permanent Total claim or in Adjudication). This is your notice that any and all of the medical records within the custody of the medical provider that you have listed may be requested by the party named on this form, as authorized by Rule R612-2-22. The medical provider is required to release the medical records per the rule, in order for the insurance carrier, self-insured employer, or the Labor Commission to make a determination in your case. *You are required to sign the “Authorization to Release Medical Records” Form 308 (I). Please list all the medical providers for industrial injury first. Please list any other medical providers who have treated you for any medical problems within the past _____ years (up to 15 years). ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________Zip_____________ ____________________________Zip_________ Telephone Number ________________________ Telephone Number ________________________ ________________________________________ ________________________________________ ________________________Zip_____________ Telephone Number ________________________ ________________________________________ ________________________________________ ____________________________Zip_________ Telephone Number ________________________ ________________________________________ ________________________________________ ________________________Zip_____________ Telephone Number ________________________ ________________________________________ ________________________________________ ____________________________Zip_________ Telephone Number ________________________ ________________________________________ ________________________________________ ________________________Zip_____________ Telephone Number ________________________ ________________________________________ ________________________________________ ____________________________Zip_________ Telephone Number ________________________ Please attach additional pages, if necessary. Name of Party Requesting the Medical Records __________________________________________________ Address __________________________________________________________________________________ Telephone Number__________________________________________________________________________ Relationship to the Claim ____________________________________________________________________ * Please see the back of this form for medical providers that you do not have to name on this form. Failure to return this form to the requester may result in a delay or denial of your claim. American LegalNet, Inc. www.USCourtForms.com To: Injured Workers Per Industrial Accidents Division Rule, R612-2-22, an injured worker may exclude naming medical providers who provided medical for the following care, unless that care is part of the industrial injury claim. 1. 2. Psychiatric care by a psychiatrist or psychologist Reproductive organ care provided by a gynecologist. Obstetrician or urologist The above medical care information may be obtained by the entities listed in the Rule by a signed approval by the Industrial Accidents Division or an Administrative Law Judge. American LegalNet, Inc. www.USCourtForms.com