Print Form Form 310 REQUEST/APPEAL FOR ADDITIONAL MEDICAL INFORMATION PLEASE PRINT OR TYPE Claimant Name _________________________ Address _______________________________ ______________________________________ Telephone Number ______________________ Employer ______________________________ Date of Birth _____________________________ Social Security Number ____________________ Date of Injury ____________________________ Insurance Company, Third Party Administrator, Self Insured Employer, or Attorney Name of Requesting Party_______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Telephone Number __________________________ Name of Insurance Carrier or Self Insured Employer ________________________________________ ___________________________________________________________________________________ Specific Medical Information Requested: 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ Reasons Additional Medical Information is Needed: _____________________________________________________________________________________ _____________________________________________________________________________________ Claimant _____ Yes, I agree to release the additional requested information _____ No, I do not agree to release the additional requested information for the following reason(s) If Yes, you agree to release the additional requested information, please complete the medical provider list for the specific information and sign the "Authorized Release for Medical Information." If No, the insurance carrier may request the Labor Commission, Division of Industrial Accidents to review the request and make a decision as to the relevance of the additional medical information requested. The decision by the Division of Industrial Accidents may be appealed by either party to the Adjudication Division of the Labor Commission. ________________________________________ Claimant Signature _______________________________ Date This form must be returned to the Requesting Party by the claimant within 10 days of the date mailed. Official Form 310 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com _______ The Insurance Carrier is requesting a review by the Industrial Accidents Division as to the relevance of the additional requested information. (A summary of the need for the additional information must accompany this form.) Determination: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Reason for Determination: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Unable to make a determination for the following reason(s): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ If unable to make a determination, the insurance carrier will have 15 days from the date of the signed determination in which to submit additional information for consideration. Absent any additional information the request for additional medical information is denied. Any determination made the Division of Industrial Accidents must be appealed to the Adjudication Division within 30 days from the date of the determination or the determination becomes final. ___________________________________________ Signature of Staff Person Making Determination ______________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com