VWC Form No. BR1 (REV 7/18/05) Page 1 of 4 THE VIRGINIA WORKERS222 COMPENSATION COMMISSION Petition Under the Virginia Birth-Related Neurological Injury Compensation Act, Pursuant to Virginia Code 247 38.2-5004 IN THE MATTER OF: Infant222s Name: VWC File No. (leave blank): I.Please complete items A through H (please attach additional sheets as necessary)A.Name and address of legal representative: Street/mailing: E-mail: B.Basis for representation of injured infant: Parent Guardian Other: C.Name and address of injured infant: Street/mailing: American LegalNet, Inc. www.FormsWorkFlow.com VWC Form No. BR1 (REV 7/18/05) Page 2 of 4 D.Name and address of any physician providing obstetrical services who was present at thebirth (please list all physicians and their addresses; if you are aware of counsel representing anyof these, please include name and address of counsel as well):Dr. Name & Address Counsel Name & Address E.Name and Address of hospital where birth occurred (if you are aware of counsel representingany of these, please include name and address of counsel as well):Hospital Name & Address Counsel Name & Address F.Description of the disability for which claim is made: G.Time and place where the birth-related neurological injury occurred:Date: Location and Address: H.Brief statement of the facts and circumstances surrounding the birth-related neurologicalinjury and giving rise to the claim: American LegalNet, Inc. www.FormsWorkFlow.com VWC Form No. BR1 (REV 7/18/05) Page 3 of 4 II.Attach the following items to this Petition:1.All available medical records relating to the birth-related neurological injury and a description ofany unavailable records of which you are aware and the reasons for their unavailability;2.Appropriate assessments, evaluations, and prognoses and such other records and documents as arereasonably necessary for the determination of the amount of compensation to be paid to, or on behalfof, the injured infant on account of a birth-related neurological injury;3.Documentation of expenses and services incurred to date, which indicates whether such expensesand services have been paid for, and if so, by whom; and4.Documentation of any applicable private or governmental source of services or reimbursementrelative to the alleged impairments. Number of Copies You Must File and Filing Fee: You must furnish the Commission with as many copies of the petition as required for service upon the Program, any physician and hospital named in the petition, the Board of Medicine and the Department of Health, along with a $15 filing fee Submit this Petition, required attachments and copies, and $15 filing fee to: The Virginia Workers222 Compensation Commission Richmond, Virginia 232 If you have questions about filing this petition or the hearing process, please contact the Commission at 804.367.8664. Some information may be available at www.vwc.state.va.us . If you have questions about benefits under the Virginia Birth-Related Neurological Injury Act, please contact the Virginia Birth-Related Neurological Injury Compensation Program at 804.330.2471. Information is also available at their website: http://www.vabirthinjury.com/ . American LegalNet, Inc. www.FormsWorkFlow.com VWC Form No. BR1 (REV 7/18/05) Page 4 of 4 Additional Information Regarding Procedures With regard to procedures after you file this petition, Virginia Code 247 38.2-5004 provides: B.Upon receipt of the petition or the filing of a claim relating to the conduct of aparticipating physician, the Department of Health Professions shall investigate thepetition or claim, utilizing the same process as it does in investigating complaints filedunder any provision contained in Title 54.1. Conduct of health care providers givingrise to disciplinary action shall be referred to the Board of Medicine for actionconsistent with the authority granted to the Board in 247247 54.1-2911 through 54.1-2928 .If a notice or order is issued by the Board of Medicine, a copy shall be mailed to thepetitioner or claimant.C.Upon receipt of the petition or the filing of a claim relating to the conduct of aparticipating hospital, the Department of Health shall investigate the petition or claim,utilizing the same process as it does in investigating complaints filed under anyprovision of Title 32.1. If it determines that there is reason to believe that the allegedinjury resulted from, or was aggravated by, substandard care on the part of the hospitalat which the birth occurred, it shall take any appropriate action consistent with theauthority granted to the Department of Health in Title 32.1.D.The Program shall file a response to the petition and submit relevant writteninformation relating to the issue of whether the injury alleged is a birth-relatedneurological injury, within the meaning of this chapter within 10 days after the date thepanel report is prepared pursuant to subsection C of 24738.2-5008 is filed with theCommission.E.Any hospital at which a birth occurred, upon receipt of written notice from the legalrepresentative of an injured infant that he intends to file a petition under this chapter,shall promptly deliver to such person all available medical records relating to the infantwho allegedly suffered a birth-related neurological injury.F.As used in this chapter, fetal monitoring strips, whether printed or in electronicformat, shall be deemed to constitute part of the medical records relating to an infantwho allegedly suffered a birth-related neurological injury. If you are viewing this form on a personal computer with an internet connection, you can view the entire Virginia Birth-Related Neurological Injury Act by clicking this link: http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+TOC38020000050000000000000 . American LegalNet, Inc. www.FormsWorkFlow.com