Free Application to Reopen Claim Due to Worsening Condition - Washington

Dept. of Labor & Industries Claims Section PO Box 44291 Olympia WA 98504-4291

Dept. of Labor & Industries Self Insurance PO Box 44892 Olympia WA 98504-4892

APPLICATION TO REOPEN CLAIM
WORKER INFORMATION Complete your portion in FULL for prompt action

DUE TO WORSENING OF CONDITION
Claim number

Important: Only use this form if your medical condition has worsened, and your claim has been closed for more than 60 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 application within 90 days of the Department's receipt of the reopening application. If you have had a new injury at work, complete a new Report of Industrial Injury or Occupational Disease form in lieu of this 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. Present home address 7. City State ZIP Address

6. Mailing address (if different than home address) 8. City State State ZIP ZIP

8a. I prefer my correspondence go to my Representative. Name: 9. Date of original injury / / 11. What are your present physical complaints? 14. Full name of doctor treating you at time of claim closure 16. Have you had any new injuries or illnesses since the date of claim closure? If yes, explain.

10. Employer at time of original injury 12. Date claim closed 13. Date condition became worse after claim closure? / / / / 15. What parts of your body are affected by this injury/ disease?

17. Did your condition worsen due to another injury or accident either on or off No If yes, explain. the job? Yes

18. Have you received any medical treatment for this condition since claim closure? If yes, list name and address of treating doctor(s). 19. Doctor Address City State ZIP+4 22. Are you working? Phone number

Yes

No Phone number

20. Doctor Address City If no, Why? Retired Unable to work State Laid off Quit

ZIP+4 23. Last date worked

21. Have you applied for or are you receiving ? (check correct box(es)) Unemployment Public assistance Sick leave Retirement benefits Disability insurance

Yes

No

Any other Industrial Insurance compensation? (i.e., Longshore harbor workers, Jones Act, Railroad)

If checked, explain.

24. Present or last employer Address City 25. Your job title and duties 26. Type of business 27. How long have you worked for this employer? Phone number State ZIP+4

28. What other employers & job titles have you had since your claim was closed?

NOTE: Persons making false statements in obtaining industrial insurance benefits are subject to civil and criminal penalties. I declare that these statement 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 & Industries and/or the Self Insured Employer.
Today's date / / F242-079-000 application to reopen claim 8-07 Claimant's signature

Dept. use only

X
CONTINUE FOR DOCTOR'S INFORMATION

Claim number

DOCTOR'S INFORMATION (complete form in FULL) Please complete this form and send it to the Department of Labor & Industries. It will enable us to determine if the current medical condition is due to a worsening of a previous work-related injury. A claim can only be reopened if there has been 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 the form. However, payment for any additional services not authorized by the department 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 appropriate address on the reverse side. Do not attach a bill to this form. 1. Please describe patient's current symptoms.

3. Are the symptoms the result of this industrial injury or occupational disease? Yes No 4a. List all the elements of your current medical findings including history, examination, and test results that would support a measurable (objective) worsening of the industrial injury or occupational disease since claim closure or the last reopening denial. Attach test results and findings.

2. What was the FIRST date you saw the patient for these symptoms after claim closure? / /

4b. Upon what information did you rely to make the comparison to substantiate worsening of the industrial injury or occupational disease. Doctor at the time of claim closure Reviewed the previous medical file Contacted the previous doctor Other: 6. Beginning date of current disability / /

5. Does the current condition prevent the patient from working? Yes No If yes, estimate number of days off work:

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 Doctor's name (type or print) Address Today's date / / City L&I provider no. / NPI # Doctor'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