14.09.01.06
A. Claim for Benefits.
(1) To initiate a claim for benefits, an employee shall file a claim form with the Commission.
(2) The Commission shall reject and return to the claimant a claim form that does not contain sufficient information to process the claim, including:
(a) The employee's name;
(b) The employee's address;
(c) The employee's date of birth;
(d) The date of the accident or occupational disease;
(e) The member of the body that was injured;
(f) A description of how the accidental injury or occupational disease occurred; and
(g) The employee's employer's name and address.
(3) If the information set forth in §A(2) of this regulation is unavailable or does not exist the claimant shall:
(a) Enter all zeros (0) in the spaces provided for the information; and
(b) Attach a signed statement certifying that the information is unavailable or does not exist.
(4) The employee shall sign the claim form certifying that the information submitted on the claim form is accurate.
(5) When completing the claim form, the claimant shall sign an authorization for disclosure of health information directing the claimant's health care providers to disclose to the claimant's attorney, the claimant's employer, the employer's insurer, or any agent thereof, the claimant's medical records that are relevant to:
(a) The member of the body that was injured by an accident or occupational disease, as indicated on the claim form; and
(b) The description of how the accidental injury or occupational disease occurred, as indicated on the claim form.
(6) Revocation of Authorization.
(a) A claimant may revoke an authorization for disclosure of health information in writing.
(b) The claimant shall serve a copy of the written revocation on all parties in the case.
(7) The Commission shall reject and return to the claimant a claim form that does not contain a signed authorization for disclosure of health information.
(8) Date of Filing.
(a) A claim is considered filed on the date that a completed and signed claim form, including the signed authorization for disclosure of health information, is received by the Commission.
(b) For any claim form that has not been rejected or returned as incomplete under §A(2) of this regulation, the Commission's date of receipt is determined by the date stamp affixed on the claim form.
(9) Electronic Submission.
(a) A claim that is submitted electronically is not considered filed until the signed claim form, including the signed authorization for disclosure of health information, is received by the Commission.
(b) The Commission's date of receipt is determined by the date stamp affixed on the claim form.
B. Amendment of Claim.
(1) A claimant may amend a claim to add or remove a member of the body by filing with the Commission a claim amendment form.
(2) A claimant shall serve a copy of a claim amendment form on the parties of record.
(3) The claimant shall sign the claim amendment form certifying that the information submitted on the claim amendment form is accurate.
(4) When completing the claim amendment form, the claimant shall sign an authorization for disclosure of health information authorizing the claimant's health care providers to disclose to the claimant's attorney, the claimant's employer, the employer's insurer, or any agent thereof, the claimant's medical records that are relevant to the member of the body identified by the claim amendment form.
(5) The Commission shall reject and return to the claimant a claim amendment form that does not contain a signed authorization for disclosure of health information.