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Employee Injury or Illness Notification The employee must complete the Employee Injury or Illness Notification. The employee’s supervisor must then sign, date and return the form to the IMWCA Claims Department at 317 Sixth Avenue, Suite 800, Des Moines, IA 50309-4111. For questions on how to complete this form, contact IMWCA Claims Division at (515) 244-2708 or (800) 257-2708. Employee Information (please print or type) Name: Social Security No: Address: City: Zip Home Phone: ( Date of Occupation: Length of Employment: Employer: Accident Information Date and time of Date and time injury How did the accident happen? (please describe in detail) To whom did you report the accident? (list names) Who was present when the accident occurred? (list names) Indicate the injured part(s) of your body (specify right or left): Have you ever injured this part of your body before? (circle one) YES NO If yes, please describe: ---PAGE BREAK--- Treatment Information Does your employer require the use of a designated physician for workers’ compensation injuries? YES NO If so, list doctor’s name: From whom did you first receive medical Phone Number: ( Street address of facility: Street address of facility: Date of first Are you still receiving treatment? YES NO If yes, explain the type, frequency and length of anticipated treatment: Return to Work Did you miss more than three days of work? (circle one) YES NO If no, skip the rest of the questions and sign the form. On what date did you return to If not working, when do you expect to return to work?_____ Has your physician placed restrictions on your activities? YES NO If yes, explain: Is there any job you can do with these restrictions? YES NO If yes, what Did you discuss light duty with your supervisor? YES NO The information in the box below must be completed if the employee missed more than three days of work. *This wage information and maximum exemptions are used to calculate workers’ compensation rates for compensable claims. BE AS ACCURATE AS POSSIBLE. Marital Are your earnings based on hourly wages? Are you 65 or If so, Is your spouse 65 or (hourly rate) (no. of hrs) Are you blind? If not based on hourly wages, show weekly earnings and Is your spouse how computed: Number of dependent children:__________ Other dependents?__________ If gross wages vary, supply total earnings for last completed Number of hours you normally period of 13 weeks: 13 weeks = $ work each Wage documentation must be attached to this report for all lost time claims. Employee’s Signature (date signed) Supervisor’s Signature (date signed) Please fax or e-mail this completed form to: (515) 288-3848 or [EMAIL REDACTED] ---PAGE BREAK--- AUTHORIZATION TO RELEASE INFORMATION Name of Patient: Date of birth: I. AUTHORIZATION FOR RELEASE OF INFORMATION AND FOR REDISCLOSURE I authorize whose address is __to disclose and deliver to Iowa Municipalities Workers' Compensation Association, whose address is 317 Sixth Avenue, Des Moines, IA 50393-3688, the following information: any and all medical records, including those predating the date of injury and initial patient questionnaire NOTE: If information includes mental health treatment , substance abuse treatment or HIV-related information it will not be released unless you agree to the release on the reverse side of this form. I understand the information is being disclosed and may be used only for legal and/or litigation purposes relating to claims and/or suit against and/or arising out of incident(s) on or about This authorization expires on , (not to exceed one year); or, if no date is specified, on the termination of the litigation or other proceedings for which this authorization was provided. I understand that I may refuse to sign this authorization or revoke this authorization at any time. I understand that my revocation or refusal to sign this authorization will not affect my ability to obtain health care services. I also understand that if I revoke, the revocation will take effect on the day it is received by the entity from whom disclosure is sought in writing. I understand that if the person or entity that receives the information requested is not covered by the federal privacy regulations or is not an individual or entity who has signed an agreement with such a person or entity, the information described above may be redisclosed and will no longer be protected by the regulations. Iowa and/or Federal law provides that I have a right to prohibit redisclosure of confidential medical information and further disclosure may not be had without my express written authorization, except as indicated below. I further understand that the Recipient, WITHOUT FURTHER AUTHORIZATION, may redisclose said information to Parties and their legal counsel, insurers, experts, potential experts, anyone against whom claim is or has been made, administrative agency and court officials hearing the claim, and any agents, employees, or representatives of any of said persons I SPECIFICALLY AUTHORIZE AND CONSENT TO THE DISCLOSURE AND REDISCLOSURE DESCRIBED ABOVE. X Signature of Patient or patient's legal representative Date Name and relationship of patient's legal representative: Il. AUTHORIZATION FOR CONSULTATION I understand that if the person or entity listed above is a physician, surgeon, physician's assistant, advanced registered nurse practitioner or mental health professional (provider) this authorization also permits to consult with that provider about my medical history and condition relating to my claims described above, and further permits that health professional to render opinions regarding the cause of my condition and the prognosis for that condition. l understand that if the lawyer seeking consultation represents a party adverse to me, that lawyer shall provide a written notice to my lawyer and other counsel consistent with the Iowa Rules of Civil Procedure for service of a notice of deposition at least ten (10) days prior to such consultation. In order for the above consultation to be authorized, sign here and at the end of Section. X Signature of Patient or patient's legal representative Date Name and relationship of patient's legal representative: