Common use of Medical Only Clause in Contracts

Medical Only. The parties agree to an award for payment of medical benefits that are reasonable, necessary, authorized and causally related to the compensable injury. THIS AGREEMENT IS SUBJECT TO ADJUSTMENT AND APPROVAL BY THE COMMISSION PURSUANT TO THE VIRGINIA WORKERS’ COMPENSATION ACT Signatures REQUIRED By signing below, we certify that the facts relating to this accident are correct as presented on this form and agree that the Injured Worker shall receive compensation or benefits indicated until suspended in accordance with the provisions of the Virginia Workers’ Compensation Act. Signature of Injured Worker Print Name Date (m/d/yyyy) Signature of Claim Administrator Print Name Date (m/d/yyyy) Print Name and Address of Claim Administrator Phone Number Print Name and Address of Injured Worker’s Attorney Phone Number Award Agreement Form #50 Filing Instructions

Medical Only. The parties agree to an award for payment of medical benefits that are reasonable, necessary, authorized and causally related to the compensable injury. THIS AGREEMENT IS SUBJECT TO ADJUSTMENT AND APPROVAL BY THE COMMISSION PURSUANT TO THE VIRGINIA WORKERS’ COMPENSATION ACT Signatures REQUIRED By signing below, we certify that the facts relating to this accident are correct as presented on this form and agree that the Injured Worker shall receive compensation or benefits indicated until suspended in accordance with the provisions of the Virginia Workers’ Compensation Act. Signature of Injured Worker Print Name Date (m/d/yyyy) Signature on behalf of Claim Administrator the Employer/Insurer Print Name Date (m/d/yyyy) Print Name and Address of Claim Administrator Phone Number Print Name and Address of Injured Worker’s Attorney Phone Number This form is required by the Virginia Workers’ Compensation Commission VWC Form #4 Rev. 10/08 Award Agreement VWC Form #50 4 Filing Instructions