RELATES TO:, , , , ,
NECESSITY, FUNCTION, AND CONFORMITY:requires the Executive Director of the Office of Workers' Claims to promulgate administrative regulations necessary to implement KRS Chapter 342. requires that a question arising under KRS Chapter 342 which is not settled by agreement of the parties shall be determined by an administrative law judge. requires the executive director to promulgate administrative regulations to expedite the payment of medical expense benefits. This administrative regulation establishes a procedure for the resolution of a medical dispute before an administrative law judge.
AFFIDAVIT OF EMPLOYEE
Affiant, (Name), first being duly sworn, states that the attached Request for Expedited Determination of Medical Issue (Form 120EX) concerns treatment for a condition compensable under the Kentucky Workers' Compensation Act. Affiant further states as follows:
Subscribed and sworn to before me by (name) this (day) day of (month), (year). Notary Public: My commission expires:
AFFIDAVIT OF PHYSICIAN EXPEDITED MEDICAL DISPUTE
Affiant (Name), a physician whose area of specialization is (specialization), first being duly sworn, states that the attached Request for Expedited Determination of Medical Issue (Form 120EX) concerns a work-related injury or disease.
Affiant further states that failure of (Name of workers' compensation patient) to obtain or undertake this proposed medical care within the next forty-five (45) days could lead to serious physical or mental disability or death because:
W.C. Medical Index No.:
Subscribed and sworn to before me by
(name) this (day) day of (month), (year).
My commission expires:
803 KAR 25:012
STATUTORY AUTHORITY:, ,