Claims Form

Claims Form Exhibit “A” MS Insurance Department Use Only: Application #: Receipt Date: _____Approved _____ Disapproved Claimant type: ___ Law Enforcement Officer ____ Fire Fighter APPLICATION FOR BENEFITS FIRST RESPONDER HEALTH AND SAFETY ACT TRUST FUND Mail to: MISSISSIPPI INSURANCE DEPARTMENT c/o LEGAL DIVISION – FIRST RESPONDER FUND P.O. Box 79 Jackson, MS 39205-0079 Email to: FirstResponderFund@mid.ms.gov A. APPLICANT INFORMATION – to be completed and signed by the APPLICANT or legal representative. Applicant’s Name:________________________ SSN:_____________________________ If applying on behalf of a deceased first responder, please provide your name and relationship to deceased first responder __________________________________________________ (Name) (Relationship) Date of Birth (mm/dd/yyyy)__________________ Gender: _______Male ________Female Street Address:______________________________________________________________ Street (Apt.#) City State Zip Code Mailing Address:_____________________________________________________________ City State Zip Code Home Phone Number_______________________ Cell/Other Number_________________ Email Address:_____________________________________________________________ Employer Name and Address (Fire District if Volunteer Fire Fighter): Please indicate if you are a Firefighter:____________________ Volunteer:_______________ Law enforcement officer_________________________ Please indicate dates of service:___________________________________________ Date of diagnosis:____________/___________/__________ Tell us about your diagnosis, type, and prognosis: ______________________________________________________________________________ Have you filed or do you plan to file for Workers’ Compensation relating to this diagnosis? _______________________Yes _________________________No Physician/Healthcare Provider Information: Physician Name:_______________________________________________________ Mailing Address:________________________________________________________ Phone Number: _________________________ Fax Number:__________________ Email Address:___________________________________________________________ Type of Benefits Requesting: __________________Lump Sum ___________________Monthly Benefits Certification: I hereby certify that the above information is true and complete to the best of my knowledge. I know that any misrepresentation herein may lead to a rejection of this application and the Mississippi Insurance Department has the right to pursue civil and/or criminal action for the misrepresentation of such information. _________________________________________________ ________________________ Applicant’s Signature Date _____________________________________________________ ________________________ Representative (If signing on behalf of a deceased first responder) Date B. PHYSICIAN CERTIFICATION. To be completed and signed by the PHYSICIAN treating you for event. Diagnois/Condition:____________________________________________________________ Does the applicant’s cancer diagnosis meet the following definition: A disease caused by an uncontrolled division of abnormal cells in a part of the body or a malignant growth or tumor resulting from the division of abnormal cells. “Cancer” is limited to cancer affecting the bladder, brain, colon, liver, pancreas, skin, kidney, gastrointestinal tract, reproductive tract, leukemia, lymphoma, multiple myeloma, prostate, testicles and breast. Yes__________________________________ No______________________________ If no, the applicant does not meet the criteria for benefits under the Fund. Please identify if the cancer is metatstasized or nonmetastasized based upon the following definitions: __________ “Metastasized cancer” - the cancer is caused by an occupational hazard and that there are one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue and that either: • There is metastasis, and surgery, radiotherapy or chemotherapy is medically necessary; • There is a tumor of the prostate, provided that it is treated with radical prostatectomy or external beam therapy; or • The first responder has terminal cancer, his or her life expectancy is twenty- four (24) months or less from the date of diagnosis, and will not benefit from, or has exhausted, curative therapy. ___________ “Nonmetastasized cancer” - the cancer is caused by an occupational hazard and: • There is carcinoma in situ such that surgery, radiotherapy or chemotherapy has been determined to be medically necessary; • There are malignant tumors which are treated by endoscopic procedures alone; or • There are malignant melanomas. Has this patient been treated for the same/similar condition prior to this diagnosis? If so, list related diagnosis and dates of treatment: _______________________________________ Is this patient permanently disabled due to cancer? Yes_______________ No______________________ Is this patient temporarily disabled due to cancer? Yes_____________________ If yes, anticipated return to work date:________________ No______________________ Certification: I certify that the above information is true and complete to the best of my knowledge. I know that any misrepresentation herein may lead to a rejection of the patient’s application and the Mississippi Insurance Department has the right to pursue civil and/or criminal action for the misrepresentation of such information. ________________________________________________ _________________________ Physician Signature Date _______________________________________________ __________________________ Physician Name (Please Print) Office Phone _____________________________________________________________________________ Mailing Address City State Zip Code Email Address: _________________________________________________________________ Fax Number: _____________________________ Tax ID.:_______________________ Patient ID#:_________________________________ NOTE: Please make a copy of the employee’s signed Authorization for Release of Records (Section D) for your records. C. EMPLOYMENT INFORMATION. To be completed and signed by your EMPLOYER. Name of Employer (Fire District if Volunteer Fire Fighter) ___________________________________________________________________________ Mailing Address City State Zip Code Email Address:_________________________________________________________________ Phone Number:____________________________ Fax Number:_______________________ Employee’s Job Title:___________________________________________________________ Employee’s Dates of Service:______________________________________________________ For the purposes of determining eligibility for benefits, Section 25-15-405, Mississippi Code Annotated (1972) sets forth the following definitions: “Fire fighter” means any firefighter who has ten (10) or more years of service and is employed by the State of Mississippi, or any political subdivision thereof, on a full-time duty status, and any firefighter who has ten (10) or more years of service and is registered with the State of Mississippi, or a political subdivision thereof, on a volunteer firefighting status. “Law enforcement officer” means any officer who has been certified by the Mississippi Board on Law Enforcement Officer Standards and Training and has ten (10) or more years of service. This employee ________ does ________ does not (check one) meet the criteria of one of the above definitions. (Please attach a copy of the employee’s Professional Certificate as being qualified to be a Mississippi Law Enforcement Officer or Fire Fighter to this application.) If Applicant is requesting monthly benefit payments, please provide the average hours per week the employee worked prior to this incident: ______________________ hours/week Monthly salary $ ___________________________ Annual Salary $ ______________________________ Last work date:________________________ Has the employee returned to work?_________________Yes _____________________No If yes, please provide date employee returned to work:__________________________________ Is Applicant receiving Workers” Compensation for this medical event? ______________________Yes ____________________________No Please provide any other information you feel is pertinent to the Applicant/Employee’s application: ______________________________________________________________________________ Certification: I certify that the above information is true and complete to the best of my knowledge. I know that any misrepresentations herein may lead to a rejection of the applicant’s application and the Mississippi Insurance Department has the right to pursue civil and/or criminal action for the misrepresentation of such information. Furthermore, I will notify the Mississippi Insurance Department in writing the exact date this employee returns to work. This notification shall be submitted to the Department no later than ten days after the employee returns to work. _______________________________________________ ______________________________ Employer Name (Please Print) Title _________________________________________ ______________________________ Signature Date NOTE: Please make a copy of the employee’s signed Authorization for Release of Records (Section D) for your records. D. AUTHORIZATION FOR RELEASE OF RECORDS. To be completed by APPLICANT. For the purpose of evaluating my eligibility for benefits including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application, I hereby authorize the disclosure of information from my physician/healthcare provider and from my employer to the Mississippi Insurance Department or its authorized representatives. Health information may be disclosed by any physician or healthcare provider that has any records or knowledge about the incident referred to on this application. Non health information including earnings or employment history or any other facts deemed appropriate by the Mississippi Insurance Department or its authorized representatives to evaluate my application may be disclosed by any entity, person, or organization that has records about me, including but not limited to my employer, employer representative and compensation sources. Any information the Mississippi Insurance Department or its authorized representatives obtain pursuant to this authorization will be used only for the purpose of evaluating and administering my application for benefits. The Mississippi Insurance Department or its authorized representatives will not disclose any information unless permitted by federal and/or state laws. I further authorize the Mississippi Insurance Department to notify my employer of any benefits received and any employer responsibilities as related to my claim. This authorization is valid for two (2) years from its execution, and a copy is as valid as the original. I know that I may request a copy of this authorization to request this information. This authorization may be revoked by me at any time except to the extent the Mississippi Insurance Department or its authorized representatives have relied on the authorization prior to notice of revocation. If revoked, the Mississippi Insurance Department or its authorized representatives may not be able to evaluate my application for benefits. I may revoke this authorization by sending written notice to: Mississippi Insurance Department, c/o Legal Division - First Responder Fund, P. O. Box 79, Jackson, MS 39205. You may refuse to sign this form; however, the Mississippi Insurance Department or its authorized representatives will not be able to evaluate your application or administer your claim for benefits. I am the individual to whom this authorization applies or that person’s legal representative. _________________________________________________ ________________________ Applicant’s Signature Date _______________________________________________ _______________________ Applicant’s Printed Name SSN _____________________________________________________ ________________________ Representative (If signing on behalf of a deceased first responder) Date STATE OF MISSISSIPPI COUNTY OF ___________________________________ Personally came and appeared before me, the undersigned authority in and for said county and state, the within named _____________________________________________________, who acknowledged to me that he signed and delivered the above forgoing waiver on the date therein mentioned and for the purpose therein expressed. Given under my hand and seal of office, this day of , 20______. NOTARY PUBLIC My Commission Expires: