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If waiving medical benefits, please acknowledge by signing below:
I understand that my health insurance may not cover any medical expenses for my injury and I may be held responsible
for payment of medical expenses for my injury. I understand and have been advised that medical benefits under the
Kentucky Workers Compensation Act are payable for the cure and/or relief of my work injury although possibly
subject to time limitation. I have not been promised that any entity will automatically pay for medical expenses related
to my injury. I have conferred with my treating physician about medical treatment I may require in the future and am
satisfied that the amount being paid for the waiver of future medical benefits is adequate to provide for that treatment.
Plaintiff/Claimant Signature
If not waiving medical benefits in a claim subject to 780-week benefit limit, please acknowledge by signing below:
I understand that the Defendant/Employer or its insurance carrier remains liable for reasonable and necessary medical
benefits related to my injury, but that the liability is potentially limited as explained below. The Defendant retains the
right to challenge medical treatment by filing a medical dispute. I will receive notice of such a challenge by a Motion to
Reopen and Form 112/Medical Dispute.
The Defendant’s obligation to pay medical benefits will expire 780 weeks from the date of my injury unless I have
applied for and been granted a continuation of medical benefits. The Department of Workers Claims will mail to me a
notice letter twenty-six (26) weeks before the 780-week anniversary date of my injury explaining that the Defendant’s
liability for medical benefits will expire on that date unless I successfully apply for an extension. It is my responsibility
to notify the Department of Workers Claims of any changes to my physical or electronic mailing addresses to ensure I
receive this notice letter. My application for continuation of medical benefits must be filed within 75 days prior to the
termination of the 780-week allowance for medical benefits.
Plaintiff/Claimant Signature
If not represented by an Attorney, please acknowledge by signing below:
I understand that I have a right to obtain an Attorney of my choice to review this Agreement and by signing below; I
acknowledge that I have waived that right. By waiving that right, I understand I will be held to the same standard as an
Attorney and this Agreement will be enforceable as if represented by Attorney.
Plaintiff/Claimant Signature
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