Washington > Workers Comp > Crime Victims Compensation
Application To Reopen Claim Due To Worsening Of Condition F800-031-000 - Washington
| Application To Reopen Claim Due To Worsening Of Condition Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 APPLICATION TO REOPEN CLAIM VICTIM INFORMATION Complete your portion in FULL for prompt action DUE TO WORSENING OF CONDITION Claim number RESET Important: Benefits are limited to $50,000 per claim. If your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Only use this form if your claim has not reached the $50,000 cap, your medical condition has worsened, and your claim has been closed for more than 90 days. If time loss benefits are paid before a decision about reopening is made and your claim is not reopened, you will be required to repay those benefits. Please write your claim number above. You will receive information about your reopening request within 90 days of the department's receipt of the application. 1. Name (first, middle, last) 2. Name changed since claim No closed? Yes If yes, list previous name 3. Home phone no. 4. Soc. Sec. No. (for ID only) 5. 7. Present home address City State ZIP Address 6. 8. Mailing address (if different than home address) City State State ZIP ZIP 8a. I prefer my correspondence go to my Representative Name: 9. Date of original injury 10. Employer at time of original injury 12. Date claim closed 13. Date condition became worse after claim closure? 11. What are your present physical complaints? 14. Full name of provider treating you at time of claim closure 16. Have you had any new injuries or illnesses since the date of claim closure? No If yes, explain. Yes 15. What parts of your body are affected? 17. Did your condition worsen due to another injury or accident? Yes No If yes, explain. 18. Have you received any medical treatment for this condition since claim closure? If yes, list name and address of treating provider(s). 19. Provider Phone number Address City 21. Have you applied for or are you receiving any of these benefits? (check all that apply) Unemployment Public assistance Sick leave Retirement benefits SSI/SSA Disability insurance Medicare Worker compensation 24. Present or last employer Address 25. Type of business 26. Your job title and duties 27. How long have you worked for this employer? State ZIP+4 Yes 20. Provider Address City No Phone number State ZIP+4 Are any other Industrial Insurance compensation? (i.e., Longshore harbor workers, Jones Act, Railroad) If checked, explain 22. Are you working? No Yes If no, Why? Retired Unable to work Laid off Quit 23. Last date worked Phone number City State ZIP+4 NOTE: Persons making false statements in obtaining Crime Victims Compensation benefits are subject to civil and criminal penalties. I declare that these statements are true to the best of my knowledge and belief. In signing this form, I permit doctors, hospitals, clinics or others with medical information to release my medical records to the Department of Labor and Industries and/or the Crime Victims Compensation Program. Today's date Victim's signature Dept. use only X CONTINUE FOR PROVIDER'S INFORMATION F800-031-000 application to reopen claim 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com Claim number PROVIDER'S INFORMATION (complete form in FULL) Benefits are limited to $50,000 per claim. If the victim has met or exceeded this cap, the reopening will be denied and we will be unable to pay any further benefits. This includes reopening exams or diagnostic tests. To determine the current paid amount please call 1 800 762-3716. If the benefits paid on this claim are less than the $50,000 cap, please complete this form and send it to the Crime Victims Compensation Program. A claim can only be reopened if there is an objective worsening of the allowed condition since the date of closure and that worsening is not due to an unrelated or preexisting condition or a new injury. You will be paid for the office call and diagnostic studies necessary to complete this form. Payment for any additional services will depend on our decision on the reopening request. If the claim is reopened, benefits cannot be paid for services provided more than 60 days prior to our receipt of the form. Answer all questions completely to ensure timely action on this reopening application. Please mail to the address on the application. Bills should be sent separately. 1. Please describe patient's current symptoms. 2. What was the FIRST date you saw the patient for these 3. Are the symptoms the result of the covered injury? Yes No symptoms after claim closure? 4a. List physical or psychological examination in detail, including all objective findings referable to complaints and areas involved in your claim. If evaluating a mental condition, please give relationship of all symptoms to the covered injury. Is there a preexisting physical or psychological condition that will retard recovery? 4b. Upon what information did you rely to make the comparison to substantiate worsening? (check box) Provider at the time of claim closure Reviewed the previous medical file Contacted the previous provider Other: 5. Does the current condition prevent the patient from working? No If yes, estimate number of days off work: Yes 6. Beginning date of current disability 7a. Describe the physical limitations and/or restrictions preventing the patient from working. Please provide the basis for your opinion. 7b. Could the patient return to work with modified or different duties (light, sedentary work or transitional part time work)? 8. List all medical factors that might impede or influence the patient's recovery. 9. What is your specific curative treatment plan? Please include expected time for recovery and indicate when the patient may return to some form of work. 10. Diagnosis of condition found by examination. ICD Diagnosis Codes Provider's name (type or print) Address Today's date CVCP provider no. / NPI# City Provider's signature Phone no. State ZIP+4 X Benefits may be delayed if this form is not filled out completely Please retain a copy of this reopening application for your records F800-031-000 application to reopen claim 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
