Form 307-Medical Treatment Provider List
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1MEDICAL TREATMENT PROVIDER LIST
Form 307
PLEASE PRINT OR TYPE
Claimant Name _________________________
Social Security Number ___________________
Address _______________________________
Date of Injury ___________________________
_______________________________
Employer _______________________________
Telephone Number ______________________
“Notification to the Workers’ Compensation Claimant”
Per Labor Commission Rule R612-300-10, an injured worker who files a claim for workers’
compensation benefits is required, requested, to provide the name and address of medical providers who
have provided any medical treatment for up to the past 10 years. This is your notice that any and all of
the medical records within the custody of the medical provider that you have listed may be requested by
the party named on this form, as authorized by Rule R612-300-10.* The medical provider is required
to release the medical records per the rule, in order for the insurance carrier, self-insured employer, or
the Labor Commission to make a determination in your case.
*You are required to sign the “Authorization to Release Medical Records” Form 308.
Please list all the medical providers for industrial injuries first.
Please list any other medical providers who have treated you for medical problems within the past
_______years (up to 10 years).
______________________________________
_______________________________________
______________________________________
_______________________________________
_____________________Zip _____________
___________________________Zip _________
Telephone Number _____________________
Telephone Number _______________________
_____________________________________
_______________________________________
_____________________________________
_______________________________________
______________________Zip ____________
___________________________Zip_________
Telephone Number _____________________
Telephone Number _______________________
_____________________________________
_______________________________________
_____________________________________
_______________________________________
______________________Zip ___________
___________________________Zip _________
Telephone Number _____________________
Telephone Number _______________________
_____________________________________
_______________________________________
_____________________________________
_______________________________________
______________________Zip ___________
___________________________Zip _________
Telephone Number _____________________
Telephone Number _______________________
Please attach additional pages, if necessary.
Name of Party Requesting the Medical Records ___________________________________________
Address __________________________________________________________________________
Telephone Number ______________________
Fax ___________________________________
Relationship to the Claim ____________________________________________________________
*Medical Providers who have treated you related to your reproductive organs or for psychological problems do not have to be listed unless
you have made a claim for benefits related to these medical problems.
Failure to return this form to the requester may result in a delay or denial of your claim.
Official Form 307
Revised 03/15
State of Utah * Labor Commission * Division of Industrial Accidents
160 East 300 South * P.O. Box 146610 * Salt Lake City, UT 84114-6610 * Telephone: (801) 530-6800
Fax: (801) 530-6804 * Toll Free: (800) 530-5090 *
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