Free PDF - Oklahoma

STATE OF OKLAHOMA WORKERS' COMPENSATION COURT

Rev. 2/06

COPY

REQUEST

FORM RMD-001

SUBMIT REQUEST FORM TO COPIES TO BE RETURNED TO
1. 2.

OKLAHOMA WORKERS' COMPENSATION COURT ATTENTION: COPY REQUESTS 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918

COMPANY NAME: ATTENTION: ADDRESS: CITY/STATE/ZIP:

FEE FOR FILES PULLED

TELEPHONE: (

)

PAID
EXEMPT

9
9

FOR EACH CASE NUMBER YOU MUST USE A SEPARATE COPY REQUEST FORM, AND INCLUDE A "REQUEST FOR CLAIMS FILE INFORMATION" CARD AND A $1 SEARCH FEE, UNLESS REQUEST IS EXEMPT, AS EVIDENCED BY YOUR SIGNATURE, BELOW

INQUIRIES GENERAL INQUIRIES . . . RECORDS DEPT. (405) 522-8640 RECORDS MANAGEMENT DEPT. SUPERVISOR . . . RENEA MARTIN (405) 522-8659

CLAIMANT'S NAME

DATE OF INJURY

WORKERS' COMPENSATION COURT FILE NO.

"

FORM A

CHANGE OF PHYSICIAN Employee's First Notice of Accidental Injury & Claim for Compensation Claimant's First Notice of Death & Claim for Compensation

" Settlement Agreement (F14, F26, F1X, JP)
" ORDER Entered On
/ /

" FORM 3 " FORM 3A

" ALL ORDERS " SUBSTITUTION OF ATTORNEY

" ENTRIES OF APPEARANCE " ATTORNEY WITHDRAWALS

" FORM 3B Employee's First Notice of Occupational Disease & Claim for
Compensation

" MEDICAL REPORTS OF DR. _______________________________________ " ALL MEDICAL REPORTS " FORM 19 " FORM 20 " ENTIRE FILE
3. OTHER (Specify)
Request for Payment of Charges for Medical or Rehabilitative Service Notice of Appeal of Administrative Order Proof of Loss in Death Claim

" FORM 3E Employee's Claim for Benefits for Combined Disabilities Against Last
Employer

" FORM 3F Employee's Claim for Benefits from the Multiple Injury Trust Fund " FORM 9 Motion to Set for Trial " WITH ATTACHMENTS " FORM 10 Answer & Pretrial Stipulation Offered by Respondent " WITH ATTACHMENTS " FORM 13 Request for Prehearing Conference

Files May Contain Duplicate Documents . . . BILLING IS FOR

ALL COPIES, INCLUDING DUPLICATES

STATEMENT OF EXEMPTION By signing below, the undersigned represents and acknowledges as follows: that the undersigned meets the requirements of an exemption defined in Title 85 O.S. Section 110, as indicated below; that the information sought will not be used for any unlawful or non-exempt purpose; that any misuse of the information sought may subject the undersigned to legal sanctions. Please circle the number of the exemption that applies: EXEMPTIONS: 1. Requests made by a public officer/employee in the performance of governmental duties, or as allowed by law; 2. Requests made by an insurer, self-insured employer, third-party claims administrator, or a legal representative thereof, when necessary to process or defend a workers' compensation claim; 3. Requests made by a worker or worker's representative for the worker's claim information; 4. Disclosures made for educational or research purposes, in such a manner that the disclosed information cannot be used to identify any worker who is the subject of a claim; 5. Requests made by a health care or rehabilitation provider, or legal representative thereof, when necessary to process payment for services rendered to a worker; 6. Requests made by an employer or personnel service company where the worker executes written authorization for the search and designates the employer or personnel service company as the workers' representative for that purpose. Your Signature:______________________________________________________ Printed Name:__________________________________________________ Telephone No: _________________ Address: ____________________________ City: _______________________ State: _____ Zip: ______________

FOR COURT USE ONLY - DO NOT WRITE BELOW THIS LINE

NOTE ) ) TO INSURE PROPER CREDIT TO YOUR ACCOUNT . .

PLEASE SEND COPY OF ENTIRE INVOICE WITH YOUR CHECK
INVOICE NO: I (NOTE: ALL APPLICABLE SEARCH FEES MUST ACCOMPANY REQUESTS AND WILL NOT BE BILLED) N ____________________ TOTAL COPIES (1FIRST COPY $1.00/ADDITIONAL COPIES 50¢ EACH) ........... $ _____

INVOICE DATE:

/

/

POSTAGE ................................................................... I
CE TOTAL INVOICE AMOUNT ................................................................

O

1

PURSUANT TO 85 O.S. §95

$
$

TERM S : DUE I N 30 DAYS