Medical Proof Of Change Re Application For Reopening Claim {C-27}

C-27 - MEDICAL PROOF OF CHANGE IN CONDITION IN SUPPORT OF APPLICATION FOR REOPENING OF CLAIM FOR WORKERS' COMPENSATION VOLUNTEER FILE FIGHTERS' OR VOLUNTEER AMBULANCE WORKERS' BENEFITS. This form is used in the state of New York Workers' Compensation Board and is to be completed by the attending doctor or another doctor with knowledge of the facts. The form requires information such as the WCB Case No., Carrier Case No. (if known), date and time of the injury, address where the injury occurred, claimant's social security number, injured person's name and age, employer information, insurer information, and details about the accident or injury. The form also asks for information regarding the treatment provided, the present pathology justifying a reopening of the case, necessary treatment or apparatus, any present disability or condition not previously present, changes in permanent impairment or loss of use, the cause of the present findings and complaints, claimant's work status, work limitations (if any), and details about the latest employer. The attending doctor must sign the form and provide their type or printed name, address, telephone number, WCB Authorization No., and WCB Rating Code. Chiropractors, podiatrists, and psychologists must have their reports sworn before a notary public. The reverse side of the form includes a HIPAA Notice, stating that the filing of medical reports required for worker's compensation claims is exempt from HIPAA restrictions on the disclosure of health information. www.FormsWorkflow.com