016.14.1-302 APPENDIX A. Forms
AR ADC 016.14.1-302 APPENDIX AArkansas Administrative Code
Ark. Admin. Code 016.14.1-302 APPENDIX A
016.14.1-302 APPENDIX A. Forms
)
)
)
)
INFORMATION REQUESTED BY PUBLIC EMPLOYEES CLAIMS DIVISION ON STATE EMPLOYEE'S CLAIMS
1) CLAIMANT'S NAME
2) EMPLOYER
3) DOES EMPLOYER CONTEST THIS CLAIM?
4) IF YES, STATE ON WHAT GROUNDS
5) DATE OF INJURY
6) DATE CLAIM FILED
7) JOB TITLE AND WAGES
8) ADDITIONAL WAGES (ROOM, BOARD FURNISHED, IF ANY)
9) DATE EMPLOYEE LEFT WORK
10) HAS EMPLOYEE RETURNED TO WORK?
__________
IF SO, DATE
11) DID EMPLOYEE'S WAGES CONTINUE WHILE OFF?
IF SO, FROM WHAT SOURCE?
SICK LEAVE | FOR HOW LONG |
VACATION | FOR HOW LONG |
REGULAR SALARY | FOR HOW LONG |
IF SO, PLEASE GIVE DETAILS
NAME
TITLE
AGENCY
DATE
AUTHORIZATION FOR RELEASE OF INFORMATION
I, __________ do hereby authorize and consent that the bearer be permitted to obtain and examine copies of all hospital and medical records of every sort and kind, interview and obtain copies of all records of every sort and kind from all physicians and attendants and all employers and former employers regarding all matters relating to examination, diagnosis, care, treatment, earnings and loss of earnings.
I also hereby authorize and consent that the bearer be permitted to obtain and examine copies of all records of every sort and kind from the Social Security Administration and any of its sub-divisions.
I am willing that a photostatic copy of this authorization be as valid and effective as the original at any time hereafter irrespective of the date hereof.
SIGNED: | DATE: | |
Employee | ||
ADDRESS: | ||
SOCIAL SECURITY NUMBER:
)
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.14.1-302 APPENDIX A, AR ADC 016.14.1-302 APPENDIX A
| End of Document |