WORKERS COMPENSATION FORMS - Dial and Associates

DECLARATION PURSUANT TO LABOR CODE SECTION 4906(h)Pursuant to Labor Code Section 4906(h), I declare under penalty of perjury that I have not violated Section 139.3 and I have not offered, delivered, received, or accepted any rebate, refund, commission, preference, patronage dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for any referred examination or evaluation.

Date *

Signature *

Name *

Before signing this form, you should be aware that: “Any person who makes or causes to be made any knowingly false or fraudulent material statement or representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.”

AUTHORIZATION TO RELEASE INFORMATION TO ANOTHER PERSONComplete the following to authorize the release of your information for the purpose of legal representation of Dial & Associates PC

SECTION I: Personal Information

Name *

Address *

City *

State *

Zip Code *

Telephone number *

Date of Birth *

Place of Birth (city, state, country) *

SECTION II : Representative Information

Name

DIAL & ASSOCIATES PC

Address

505 S. VILLA REAL STE 202

City

ANAHEIM

State

CA

Zip Code

92807

Pursuant to the Privacy Act of 1974 (5 U.S.C §552a(b)), I authorize any and all information to be released to Dial & Associates PC for legal representation.
Pursuant to 28 U.S.C. §1746, I declare under the penalty of perjury under the laws of the United States of America that they foregoing is true and correct, and that I am the person named in Section 1. I understand that falsification of this statement is punishable under the provisions of 18 U.S.C. §1001 by a fine of not more than $10,000 or by imprisonment of not more than five years or both.

Signature *

Date *

EXPIRATION OF AUTHORIZATION:

If applicable, please specify a date for which authorization shall expire. If no expiration date is indicated, this authorization will remain valid unitl revoked in writing. You may revoke this authorization at any time prior to the specified expiration date by providing written notice to Dial & Associates PC

Expiration Date *

Client Privacy Notice

1. Collection of Information:

We collect personal information, including but not limited to, your name, contact information, medical records, and employment details, to assist with your workers compensation case.

2. Use of Information:

We use your personal information to provide legal services, communicate with you, and handle your workers compensation case effectively.

3. Security Measures:

We employ security measures to safeguard your personal information and ensure its confidentiality.

4. Sharing Information:

We do not share your personal information with third parties without your consent, except as required by law or necessary for case proceedings.

5. Consent:

By engaging our services, you consent to our Privacy Policy and the collection and use of your personal information as outlined herein.

6. Changes to Policy:

We may update this Privacy Policy. Any changes will be communicated to you.

I have read and agree to the Privacy Policy

Client Responsibilities and Expectations

Welcome to DIAL & ASSOCIATES PC. We appreciate the opportunity to represent you in your workers' compensation case. Effective communication and collaboration between you, the client, and our legal team are essential for a successful outcome. Please familiarize yourself with the following responsibilities and expectations to facilitate a productive working relationship.

1. Honesty and Transparency

Provide accurate and complete information regarding your injury, employment history, medical treatment, and any other relevant details related to your case.
Inform us promptly of any changes in your circumstances that may affect your case.

2. Compliance with Legal Advice

Follow the advice and recommendations provided by our legal team regarding your case, including medical treatment, legal strategy, and settlement negotiations.

3. Participation in Your Case

Attend all scheduled medical appointments, hearings, depositions, and meetings related to your case. Promptly respond to our communication and requests for information.

4. Medical Treatment and Records

Keep all medical appointments, follow prescribed treatment plans, and inform us of any changes in your medical condition.
Provide authorization for the release of your medical records to our law office.

5. Maintaining Records and Documentation

Keep a record of all expenses related to your injury, including medical bills, prescriptions, travel costs, and other out-of-pocket expenses.
Share copies of relevant documents, bills, and receipts with our office.

6. Timely Reporting of Events

Inform us promptly of any new injuries or incidents related to your employment that may impact your workers' compensation claim.

7. Professional Courtesy

Treat all law office staff and associates with respect and professionalism, understanding that they are here to assist you throughout your case.

8. Feedback and Communication

Share any concerns, questions, or feedback you may have about the progress of your case. Open communication is crucial for a successful attorney-client relationship.
By adhering to these responsibilities and expectations, we can work together effectively to achieve the best possible outcome for your workers' compensation case. If you have any questions or need further clarification on any of these points, please don't hesitate to reach out to us.
Thank you for entrusting us with your case

I have read all the Information

State of California
Department of Industrial Relations
Division of Workers' Compensation

FEE DISCLOSURE STATEMENT

If you choose to be represented by an attorney, your attorney's fees will be deducted from your benefits. The fee will be approved by the Workers' Compensation Appeals Board with consideration given to the: (1) responsibility assumed by the attorney; (2) care exercised in representing you; (3) time involved; and, (4) results obtained.

Attorney's fees normally range from 9% to 12% of the benefits awarded.

There are certain circumstances where your employer (or his/her insurer) may be liable to pay your attorney's fees. For example, if the employer disputes a permanent disability evaluation obtained when you were not represented by an attorney, your employer may be liable for any attorney fees you incur because of the dispute.

If at any time you no longer wish to be represented by the attorney, you may withdraw from representation by notifying the attorney. If you withdraw from representation, the fee amount found by a workers' compensation judge to be the fair value of any work the attorney did in your case will be deducted from your award.

Your case is being filed at the Division of Workers' Compensation at the following location:

Anaheim - AHM

The employee has been advised of the district office at which his or her case will be filed and that he or she may be required to attend conferences or hearings at this location at his or her own expense.

An Information and Assistance Officer may be able to answer your questions concerning your workers' compensation benefits at no charge to you. The Officer may be able to resolve your problems without the need for litigation.

Call this toll-free number: 1-800-736-7401

Employee's Signature *

Date *

Employee's Name

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying worker' compensation benefits or payments is guilty of a felony.

HIPAA PRIVACY FORM

Authorization for Use or Disclosure of Protected Health Information

Name *

SOCIAL SECURITY NO.If you don't have a social security number, leave blank

DATE OF BIRTH *

(Required by the Health Insurance Portability and Accountability Act - 45 CFR Parts 160 and 164)

1. I hereby authorize all medical service sources and health care providers to use and/or disclose the protected health information ("PHI") described below to my agent identified in my durable power of attorney for health care nameed *

2. Authorization for release of PHI as follows: (check one) *

a. from (date) - to (date)b. all past, present and future period

from (date) *

to (date) *

3. Authorization for release of PHI covering the period of heath care: *

a. my complete health record *including records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse)b. my complete health record with the exception of the following information (check as appropriate)

Mental Health RecordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther

please specify *

4. In addition to the authorization for release of my PHI in described in paragraphs 3 and 4 of this Authorization, I authorize information regarding my billing, my condition, treatment and prognosis to my attorney of record, Stephen F. Dial, Dial & Associates PC, 505 S. Villa Real Drive Suite 202, Anaheim, CA 9280

5. This medical information may be used for legal representation.

6. This authorization shall be in force and effect until one (1) year from date of signature or

7. I understand I have the right to revoke this authorization, in writing, at any time.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Client signature *

Date *

Kaiser Release Form

Kaiser Release Form

Patient Name *

Medical Record Number *

Birth Date *

Email *

Do not use for patient copies of or access to their medical records. Patients should go to kp.org/requestrecords to conveniently request medical records, FMLA and Disability certifications.

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION
To the Following Third-Party Recipient (Fees may be required)

Recipient Name *

Address *

City *

State *

Zip Code *

This disclosure can be used for the following purpose(s): *

LegalInsuranceMedical CertificationOther

Hospital and Medical Office records released as part of this authorization may contain references related to mental health, addiction, and HIV medical conditions documented by primary care.

I authorize the following to be disclosed for the selected time frame: *

Form Completion (a substitute form or relevant medical records may be released in lieu)Medical RecordsDiagnostic ImagesItemized Billing RecordsPharmacy CopaysMedical Copays

Check the boxes below if you want this release to include the protected treating department or HIV initial test result information. If not checked, this treating department information will be excluded.

Mental Health Treatment RecordsAddiction Medicine Treatment RecordsHIV Lab Test ResultsKaiser Permanente Oregon locations need to also check this box if they want Genetic Testing information releasedI don't want this

DURATION: Authorization shall remain in effect for 6 months from the date of signature below.
REVOCATION: You or your personal representative may cancel this authorization for future releases by submitting
a written request to the Release of Information Unit listed for your region of service found on kp.org/requestrecords.
Your cancellation will not affect information that was released prior to receipt of the written request.
REDISCLOSURE: Once this information is released, it may not be protected under federal privacy law (HIPAA).
State or other federal law may require the recipient to obtain your authorization before further disclosure.

Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization, and a note stating to whom your information was disclosed will be included in your medical record. A copy of the original authorization is valid. You have a right to a copy of this completed authorization.
We will provide the requested information in electronic format to the recipient unless the recipient contact us to make other arrangements.

Date *

Signature *

If personal representative, print name/relationship *

Signature *

VENUE AUTHORIZATION

I, *(name)

HEREBY AUTHORIZE MY WORKERS’ COMPENSATION CASE FOR INJURY DATED *

TO BE FILED AT THE ANAHEIM WORKERS’ COMPENSATION APPEALS BOARD (AHM) .

Date *

APPLICANT *

APPLICANT’S ATTORNEY:

STEPHEN F DIAL
DIAL & ASSOCIATE PC UAN 7289623
505 S VILLA REAL STE 202
ANAHEIM, CA 92807

Workers' Compensation Benefits Summary

Welcome to DIAL & ASSOCIATES PC where we are dedicated to helping you navigate the workers' compensation process. This document provides a summary of the potential benefits available to workers' compensation applicants.

1. Medical Treatment

Workers' compensation typically covers all reasonable and necessary medical treatment for your work-related injury or illness. This includes doctor's visits, surgeries, hospital stays, prescription medications, and other medical services.

2. Temporary Disability Benefits

If your injury or illness temporarily prevents you from working, you may be eligible for temporary disability benefits. These benefits aim to partially replace your lost wages during the recovery period.

3. Permanent Disability Benefits

In cases where your injury or illness results in a permanent impairment, you may be entitled to permanent disability benefits. The amount is determined based on the severity of the impairment and its impact on your ability to work.

4. Supplemental Job Displacement Benefit

If you are unable to return to your pre-injury job due to a permanent disability, you may qualify for a voucher to help pay for retraining or skill enhancement for a new job.

5. Death Benefits

In tragic cases where a work-related injury or illness leads to a worker's death, certain benefits may be available to the surviving dependents, including burial and death benefits.

6. Vocational Rehabilitation

Workers' compensation may cover vocational rehabilitation services to help you return to suitable employment after a work-related injury or illness.

7. Mileage Reimbursement

You may be eligible for reimbursement for travel expenses related to medical treatment or vocational rehabilitation.

8. Appeals Process

If your workers' compensation claim is denied or disputed, we are here to guide you through the appeals process and represent your interests to ensure you receive the benefits you deserve.

It's essential to remember that each workers' compensation case is unique, and the benefits you are eligible for may vary based on the circumstances of your case. Our team at [Law Office Name] is committed to providing personalized support and ensuring you understand your rights throughout the workers' compensation process.

For more detailed and personalized information regarding your specific case, please consult with our experienced workers' compensation attorney or one of our knowledgeable law office staff members.

I have read all the information