Nev. Admin. Code § 616A.480 - Use, alteration, printing and distribution of certain posters and forms
1. The following posters and forms or data
must be used by an insurer, employer, injured employee, provider of health
care, organization for managed care or third-party administrator in the
administration of claims for workers' compensation:
(a) D-1, Informational Poster - Displayed by
Employer. The informational poster must include the language contained in Form
D-2, and the name, business address, telephone number and contact person of:
(1) The insurer;
(2) The third-party administrator, if
applicable;
(3) The organization
for managed care or providers of health care with whom the insurer has
contracted to provide medical and health care services, if applicable;
and
(4) The name, business address
and telephone number of the insurer's or third-party administrator's adjuster
in this State that is located nearest to the employer's place of
business.
(b) D-2, Brief
Description of Rights and Benefits.
(c) C-1, Notice of Injury or Occupational
Disease (Incident Report). One copy of the form must be delivered to the
injured employee, and one copy of the form must be retained by the employer.
The language contained in Form D-2 must be printed on the reverse side of the
employee's copy of the form, or provided to the employee as a separate document
with an affirmative statement acknowledging receipt.
(d) C-3, Employer's Report of Industrial
Injury or Occupational Disease. A copy of the form must be delivered to or the
form must be filed by electronic transmission with the insurer or third-party
administrator. The form signed by the employer must be retained by the
employer. A copy of the form must be delivered to the injured employee. If the
employer files the form by electronic transmission, the employer must:
(1) Transmit all fields of the form that are
required to be completed, as prescribed by the Administrator.
(2) Sign the form with an electronic symbol
representing the signature of the employer that is:
(I) Unique to the employer;
(II) Capable of verification; and
(III) Linked to data in such a manner that
the signature is invalidated if the data is altered.
(3) Acknowledge on the form that he or she
will maintain the original report of industrial injury or occupational disease
for 3 years.
If the employer moves from or ceases operation in this State, the employer shall deliver the original form to the insurer for inclusion in the insurer's file on the injured employee within 30 days after the move or cessation of operation.
(e) C-4, Employee's Claim for
Compensation/Report of Initial Treatment. A copy of the form must be delivered
to the insurer or third-party administrator. A copy of the form must be
delivered to or the form must be filed by electronic transmission with the
employer. A copy of the form must be delivered to the injured employee. The
language contained in Form D-2 must be printed on the reverse side of the
injured employee's copy of the form or provided to the injured employee as a
separate document with an affirmative statement acknowledging receipt. The
original form signed by the injured employee and the health care provider who
conducted the initial examination of the injured employee must be retained by
that health care provider. If the health care provider who conducted the
initial examination files the form by electronic transmission, the health care
provider must:
(1) Transmit all fields of the
form that are required to be completed, as prescribed by the
Administrator.
(2) Sign the form
with an electronic symbol representing the signature of the health care
provider that is:
(I) Unique to the health
care provider;
(II) Capable of
verification; and
(III) Linked to
data in such a manner that the signature is invalidated if the data is
altered.
(3) Acknowledge
on the form that he or she will maintain the original form for the claim for
compensation for 3 years.
If the health care provider who conducted the initial examination moves from or ceases treating patients in this State, the health care provider shall deliver the original form to the insurer for inclusion in the insurer's file on the injured employee within 30 days after the move or cessation of treatment of patients. As used in this paragraph, "health care provider" means a physician, chiropractic physician, physician assistant of advanced practice registered nurse.
(f) D-5, Wage Calculation Form for Claims
Agent's Use.
(g) D-6, Injured
Employee's Request for Compensation.
(h) D-7, Explanation of Wage
Calculation.
(i) D-8, Employer's
Wage Verification Form.
(j) D-9a,
Permanent Partial Disability Award Calculation Work Sheet.
(k) D-9b, Permanent Partial Disability Award
Calculation Work Sheet for Disability Over 30 Percent Body Basis.
(l) D-9c, Permanent Work-Related Mental
Impairment Rating Report Work Sheet.
(m) D-10a, Election of Lump Sum Payment of
Compensation.
(n) D-10b, Election
of Lump Sum Payment of Compensation for Disability Greater than 30
Percent.
(o) D-11,
Reaffirmation/Retraction of Lump Sum Request.
(p) D-12a, Request for Hearing - Contested
Claim.
(q) D-12b, Request for
Hearing - Uninsured Employer.
(r)
D-13, Injured Employee's Right to Reopen a Claim Which Has Been
Closed.
(s) D-14, Permanent Total
Disability Report of Employment.
(t) D-15, Election for Nevada Workers'
Compensation Coverage for Out-of-State Injury.
(u) D-16, Notice of Election for Compensation
Benefits Under the Uninsured Employer Statutes.
(v) D-17, Employee's Claim for Compensation -
Uninsured Employer.
(w) D-18,
Assignment to Division for Workers' Compensation Benefits.
(x) D-21, Fatality Report.
(y) D-22, Notice to Employees - Tip
Information.
(z) D-23, Employee's
Declaration of Election to Report Tips.
(aa) D-24, Request for Reimbursement of
Expenses for Travel and Lost Wages.
(bb) D-25, Affirmation of Compliance with
Mandatory Industrial Insurance Requirements.
(cc) D-26, Application for Reimbursement of
Claim-Related Travel Expenses.
(dd)
D-27, Interest Calculation for Compensation Due.
(ee) D-28, Rehabilitation Lump Sum
Request.
(ff) D-29, Lump Sum
Rehabilitation Agreement.
(gg)
D-30, Notice of Claim Acceptance.
(hh) D-31a, Notice of Intention to Close
Claim.
(ii) D-31b, Notice of
Circumstances Under Which a Claim May be Closed Under subsection 2 of NRS 616C.235.
(jj) D-31c, Notice of
Intention to Close Claim of Less Than $800 in Medical Benefits in 12 Months -
No Permanent Partial Disability Evaluation.
(kk) D-31d, Notice of Intention to Close
Claim of Less Than $800 in Medical Benefits in 12 Months - Permanent Partial
Disability Evaluation Scheduled.
(ll) D-32, Authorization Request for
Additional Chiropractic Treatment.
(mm) D-33, Authorization Request for
Additional Physical Therapy Treatment.
(nn) D-34, Health Insurance Claim Form (CMS
1500 Billing Form).
(oo) D-35,
Request for Assignment of Rating Physician or Chiropractic Physician.
(pp) D-36, Request for Additional Medical
Information and Medical Release.
(qq) D-37, Insurer's Subsequent Injury
Checklist.
(rr) D-38, Index of
Claims System - Claim Registration.
(ss) D-39, Physician's and Chiropractic
Physician's Progress Report - Certification of Disability.
(tt) D-43, Employee's Election to Reject
Coverage and Election to Waive the Rejection of Coverage for Excluded
Persons.
(uu) D-44, Election of
Coverage by Employer; Employer Withdrawal of Election of Coverage.
(vv) D-45, Sole Proprietor
Coverage.
(ww) D-46, Temporary
Partial Disability Calculation Worksheet.
(xx) D-52, CMS (UB-92).
(yy) D-53, Alternative Choice of Physician or
Chiropractic Physician.
2. In addition to the forms specified in
subsection 1, the following forms must be used by each insurer in the
administration of a claim for an occupational disease:
(a) OD-1, Firefighters and Police Officers
Medical History Form.
(b) OD-2,
Firefighters and Police Officers Lung Examination Form.
(c) OD-3, Firefighters and Police Officers
Extensive Heart Examination Form.
(d) OD-4, Firefighters and Police Officers
Limited Heart Examination Form.
(e)
OD-5, Firefighters and Police Officers Hearing Examination Form.
(f) OD-6, Sample Letter.
(g) OD-7, Important Information Regarding
Physical Examinations for Police Officers and Firefighters.
(h) OD-8, Occupational Disease Claim
Report.
3. The forms
listed in this section must be accurately completed, including, without
limitation, a signature and a date if required by the form. An insurer or
employer may designate a third-party administrator as an agent to sign any form
listed in this section.
4. An
insurer, employer, injured employee, provider of health care, organization for
managed care or third-party administrator may not use a different form or
change a form without the prior written approval of the
Administrator.
5. The Workers'
Compensation Section will post the following forms on its Internet website:
(a) C-4, Employee's Claim for
Compensation/Report of Initial Treatment;
(b) D-12b, Request for Hearing - Uninsured
Employer;
(c) D-16, Notice of
Election for Compensation Benefits Under the Uninsured Employer
Statutes;
(d) D-17, Employee's
Claim for Compensation - Uninsured Employer; and
(e) D-18, Assignment to Division for Workers'
Compensation Benefits.
6. Each insurer or third-party administrator
is responsible for printing and distributing all other forms listed in this
section. The provisions of this subsection do not prohibit an insurer,
employer, provider of health care, organization for managed care or third-party
administrator from providing any form listed in this section.
7. Upon the request of the Administrator, an
insurer, employer, provider of health care, organization for managed care or
third-party administrator shall submit to the Administrator a copy of any form
used in this State by the insurer, employer, provider of health care,
organization for managed care or third-party administrator in the
administration of claims for workers' compensation.
Notes
NRS 616A.400
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