New York > Workers Compensation
Medical Proof Of Change In Condition In Support Of Application For Reopening Of Claim C-27 - New York
| Medical Proof Of Change In Condition In Support Of Application For Reopening Of Claim Form. This is a New York form and can be used in Workers Compensation . |
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DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC (800)877-1373/Hemp.(866)805-3630/Haup.(866)681-5354/Peek.(866)746-0552 100 Broadway State Office Building 295 Main Street 935 James St. 130 Main Street W. Suite 400 Menands 44 Hawley Street ALBANY 12241 BINGHAMTON 13901 BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 (866) 802-3730 (866) 211-0644 (866) 211-0645 (866) 750-5157 (866) 802-3604 CHECK TYPE OF DOCTOR PHYSICIAN PODIATRIST CHIROPRACTOR PSYCHOLOGIST State of New York WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. MEDICAL PROOF OF CHANGE IN CONDITION IN SUPPORT OF APPLICATION FOR REOPENING OF CLAIM FOR WORKERS' COMPENSATION, VOLUNTEER FIRE FIGHTERS' OR VOLUNTEER AMBULANCE WORKERS' BENEFITS This report must be signed personally by the attending doctor or by some other doctor having knowledge of the facts. If doctor renders treatment in a case, including treatment for an occupational disease, C-4 (or PS-4 by psychologists) reports must also be filed. File the signed original of each report with (1) CHAIR, WORKERS' COMPENSATION BOARD at the office of the district in which the accident occurred and file a signed copy with (2) the INSURANCE CARRIER, if known, or the EMPLOYER. ANSWER ALL QUESTIONS FULLY - TYPEWRITER OR COMPUTER PREPARATION IS STRONGLY RECOMMENDED WCB CASE NO. (If Known) CARRIER CASE NO. (If Known) DATE OF INJURY AND TIME ADDRESS WHERE INJURY OCCURRED (City, Town or Village) CLAIMANT'S SOCIAL SECURITY NO. NAME ADDRESS Last Name Age APT. NO. INJURED PERSON* EMPLOYER (at the time of First Name Middle Initial accident) INSURANCE CARRIER * If patient claims that injury occurred while performing assigned duty as a Volunteer Firefighter or Volunteer Ambulance Worker, show as EMPLOYER the city, town, village, district or ambulance company against which the claim is made and enter "x" here: 1. 2. VF/VAW (a) When did YOU first treat claimant? ____________________(b) last treat claimant?_______________________(c) Are you still treating?__________ State in patient's own words how accident or injury occurred:__________________________________________________________________________ ____________________________________________________________________________________________________________________________ 3. 4. Did you communicate with claimant's last attending doctor to ascertain medical findings present at time of discharge?___________________________ State the present pathology which in your opinion warrants a reopening of this case:_______________________________________________________ ____________________________________________________________________________________________________________________________ 5. Describe treatment or apparatus now necessary:____________________________________________________________________________________ ____________________________________________________________________________________________________________________________ 6. Describe any present disability or condition not present at time case was last closed:______________________________________________________ ____________________________________________________________________________________________________________________________ 7. 8. 9. s Is there any permanent defect?________________________________________If o, what is percentage loss or loss of use?______________________ In your opinion was the accident or injury as above described a competent producing cause for the present findings and complaints?________________ Is claimant working? ________________(a)Able to do usual work?____________________________When?____________________________________ (b) Able to do any work?_______________________________________________________________When?___________________________________ (c) Specify work limitations, if any:________________________________________________________________________________________________ Last day worked_____________________ 10. Name of latest employer_____________________________________________________________________ Address_____________________________________________________________________________________________________________________ Typed or Printed Name of Attending Doctor Address Telephone No. W.C.B. Authorization No. W.C.B. Rating Code PHYSICIANS COMPLETE THE FOLLOWING I state that I am a physician, authorized by law to practice in the State of New York, am not a party to this proceeding, am the physician who subscribed to the above (or attached) report, have read the name and know the contents thereof; that the same is true to my knowledge, except as to the matters stated to be on information and belief, and as to those matters I believe it to be true. Affirmed as true under the penalty or perjury. Written Signature (Facsimile Not Accepted) Date IMPORTANT: BY LAW CHIROPRACTOR'S, PODIATRIST'S AND PSYCHOLOGIST'S REPORTS MUST BE SWORN TO BEFORE A NOTARY PUBLIC. State of New York ) ss: County of , being duly sworn, deposes and says: ) That (s)he is the , duly licensed in the State of New York, who subscribed to the above (or attached) report; and that (s)he has read the same and knows the contents thereof; that the same is true to the knowledge of deponent, except as to the matters stated to be on information and belief, and as to those matters (s)he believes it to be true. Subscribed and sworn before me this day of , (Signature of Notary Public) www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com C-27 (1-11) ANSWER ALL QUESTIONS, AVOID USE OF INDEFINITE TERMS. - See Reverse for HIPAA Notice Statewide Fax Line: 877-533-0337 HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. C-27 Reverse (1-11) American LegalNet, Inc. www.FormsWorkFlow.com
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