Request for Hearing By Administrative Law Judge--Internet Version (i501)

IAPPEALS MEDICAL
SCREEN SHOTS

Table of Contents
Section: Entry, Restart, and Exit Pages ...................................................................................................... 3
Welcome page (Wlcm001) ............................................................................................................................................. 3
Electronic Appeals Terms of Service (Tos001).................................................................................................................. 4
Screening: Information about the Applicant (Scrn001) ..................................................................................................... 6
Who is entering this appeal (Entr001) ............................................................................................................................. 6
Return to Saved appeal (Rtrn001) ................................................................................................................................... 7
Confirm your identity (Cfid001) ...................................................................................................................................... 8
1st Party: Exiting the Application (Exit001-1) .................................................................................................................... 11
3rd Party: Exiting the Application (Exit001-3) .................................................................................................................... 11

Section: Identification Pages ................................................................................................................. 12
1st Party: Re-entry Number (Rnty001-1) ......................................................................................................................... 12
3rd Party: Re-entry Number (Rnty001-3) ........................................................................................................................ 13
3rd Party: Form Completer: Preparer's Info (Frmc001) .................................................................................................... 14
1st Party: Applicant Information (Appd001-1) ................................................................................................................. 15
3rd Party: Applicant Information (Appd001-3) .................................................................................................................. 16
1st Party: Representative Info (Rpnp001-1) ..................................................................................................................... 17
3rd Party: Representative Info (Rpnp001-3) .................................................................................................................... 18
1st Party: Request for Hearing (Appl001hr-1) .................................................................................................................. 19
3rd Party: Request for Hearing (Appl001hr-3).................................................................................................................. 19
1st Party: Request for Reconsideration (Appl001rec-1) ................................................................................................... 20
3rd Party: Request for Reconsideration (Appl001rec-3) ................................................................................................... 20

Section: Medical Pages ......................................................................................................................... 21
1st Party: Contact Information (Cnti001-1) ..................................................................................................................... 21
3rd Party: Contact Information (Cnti001-3) .................................................................................................................... 21
1st Party: Change in Medical Conditions (Cicd001-1) ...................................................................................................... 22
3rd Party: Change in Medical Conditions (Cicd001-3) ..................................................................................................... 22
1st Party: Medical Treatment (Nmed001-1)..................................................................................................................... 23
3rd Party: Medical Treatment (Nmed001-3) .................................................................................................................... 23
1st Party: List of Doctors and Hospitals (Doho001-1) ...................................................................................................... 24
3rd Party: List of Doctors and Hospitals (Doho001-3) ...................................................................................................... 24
1st Party: Specific Doctor Detailed Information (Doct002-1)............................................................................................ 25
3rd Party: Specific Doctor Detailed Information (Doct002-3) ........................................................................................... 27
1st Party: Specific Hospital Detailed Information (Hosp002-1) ........................................................................................ 29
3rd Party: Specific Hospital Detailed Information (Hosp002-3) ........................................................................................ 31
1st Party: List of Tests (Test001-1) .................................................................................................................................. 33
3rd Party: List of Tests (Test001-3) .................................................................................................................................. 33
1st Party: Specific Test Detailed Information (Test002-1) ................................................................................................. 34
3rd Party: Specific Test Detailed Information (Test002-3) ................................................................................................. 36

1st Party: List of Medicines (Medi001-1) ......................................................................................................................... 37
3rd Party: List of Medicines (Medi001-3)......................................................................................................................... 37
1st Party: Specific Medicine Detailed Information (Medi002-1) ........................................................................................ 38
3rd Party: Specific Medicine Detailed Information (Medi002-3)........................................................................................ 41
1st Party: Other Medical Records (Othr001-1)................................................................................................................. 42
3rd Party: Other Medical Records (Othr001-3) ................................................................................................................ 43
1st Party: Details of Other Medical Information (Othr002-1) ............................................................................................ 44
3rd Party: Details of Other Medical Information (Othr002-3) ............................................................................................ 46

Section: Activities and Training Pages ..................................................................................................... 48
1st Party: Activities (Actv001-1) ..................................................................................................................................... 48
3rd Party: Activities (Actv001-3) ..................................................................................................................................... 48
1st Party: Work, Education & Training (Wetr001-1) .......................................................................................................... 49
3rd Party: Work, Education & Training (Wetr001-3) .......................................................................................................... 49
1st Party: Vocational Rehabilitation (Voct001-1) ............................................................................................................. 50
3rd Party: Vocational Rehabilitation (Voct001-3) ............................................................................................................. 51

Section: Review and Submit Pages ......................................................................................................... 52
1st Party: Remarks (Rmks001-1) .................................................................................................................................... 52
3rd Party: Activities (Actv001-3) ..................................................................................................................................... 53
1st Party: Medical Release Form (Mdrf001-1).................................................................................................................. 54
3rd Party: Medical Release Form (Mdrf001-3) ................................................................................................................. 55
1st Party: Summary (Revw001-1) ................................................................................................................................... 56
3rd Party: Summary (Revw001-3) .................................................................................................................................. 59
1st Party: File Attachment (Flup001-1) ........................................................................................................................... 62
3rd Party: File Attachment (Flup001-3) ........................................................................................................................... 63
1st Party: Application Submission Confirmation (Conf001-1) .......................................................................................... 64
3rd Party: Application Submission Confirmation (Conf001-3) .......................................................................................... 64
3rd Party - Appointed Representative: Application Submission Confirmation (Conf001-3-Rep) ......................................... 65
Receipt (Rcpt001) ........................................................................................................................................................ 66
Electronically Signed Medical Authorization (Form827) .................................................................................................. 69
Cover Sheet (Covr001) .................................................................................................................................................. 71

Section: Entry, Restart, and Exit Pages
Welcome page (Wlcm001)

Electronic Appeals Terms of Service (Tos001)

Screening: Information about the Applicant (Scrn001)

Who is entering this appeal (Entr001)

Return to Saved appeal (Rtrn001)

Confirm your identity (Cfid001)

1st Party: Exiting the Application (Exit001-1)

3rd Party: Exiting the Application (Exit001-3)

Section: Identification Pages
1st Party: Re-entry Number (Rnty001-1)

3rd Party: Re-entry Number (Rnty001-3)

3rd Party: Form Completer: Preparer's Info (Frmc001)

1st Party: Applicant Information (Appd001-1)

3rd Party: Applicant Information (Appd001-3)

1st Party: Representative Info (Rpnp001-1)

3rd Party: Representative Info (Rpnp001-3)

1st Party: Request for Hearing (Appl001hr-1)

3rd Party: Request for Hearing (Appl001hr-3)

1st Party: Request for Reconsideration (Appl001rec-1)

3rd Party: Request for Reconsideration (Appl001rec-3)

Section: Medical Pages
1st Party: Contact Information (Cnti001-1)

3rd Party: Contact Information (Cnti001-3)

1st Party: Change in Medical Conditions (Cicd001-1)

3rd Party: Change in Medical Conditions (Cicd001-3)

1st Party: Medical Treatment (Nmed001-1)

3rd Party: Medical Treatment (Nmed001-3)

1st Party: List of Doctors and Hospitals (Doho001-1)

3rd Party: List of Doctors and Hospitals (Doho001-3)

1st Party: Specific Doctor Detailed Information (Doct002-1)

3rd Party: Specific Doctor Detailed Information (Doct002-3)

1st Party: Specific Hospital Detailed Information (Hosp002-1)

3rd Party: Specific Hospital Detailed Information (Hosp002-3)

1st Party: List of Tests (Test001-1)

3rd Party: List of Tests (Test001-3)

1st Party: Specific Test Detailed Information (Test002-1)

3rd Party: Specific Test Detailed Information (Test002-3)

1st Party: List of Medicines (Medi001-1)

3rd Party: List of Medicines (Medi001-3)

1st Party: Specific Medicine Detailed Information (Medi002-1)

3rd Party: Specific Medicine Detailed Information (Medi002-3)

1st Party: Other Medical Records (Othr001-1)

3rd Party: Other Medical Records (Othr001-3)

1st Party: Details of Other Medical Information (Othr002-1)

3rd Party: Details of Other Medical Information (Othr002-3)

Section: Activities and Training Pages
1st Party: Activities (Actv001-1)

3rd Party: Activities (Actv001-3)

1st Party: Work, Education & Training (Wetr001-1)

3rd Party: Work, Education & Training (Wetr001-3)

1st Party: Vocational Rehabilitation (Voct001-1)

3rd Party: Vocational Rehabilitation (Voct001-3)

Section: Review and Submit Pages
1st Party: Remarks (Rmks001-1)

3rd Party: Activities (Actv001-3)

1st Party: Medical Release Form (Mdrf001-1)

3rd Party: Medical Release Form (Mdrf001-3)

1st Party: Summary (Revw001-1)

3rd Party: Summary (Revw001-3)

1st Party: File Attachment (Flup001-1)

3rd Party: File Attachment (Flup001-3)

1st Party: Application Submission Confirmation (Conf001-1)

3rd Party: Application Submission Confirmation (Conf001-3)

3rd Party - Appointed Representative: Application Submission Confirmation (Conf001-3-Rep)

Receipt (Rcpt001)

Electronically Signed Medical Authorization (Form827)

Cover Sheet (Covr001)