Application To Reopen Partial Disability Claim

12 . ty, pension, etc.) you are receiving. PLEASE PR I NT OR TYPE Claimant Complete Section I of this form and submit it to your doctor. He or she must then complete Section II of this form in detail, and must attach a narrative report if necessary. SECTION I TO BE COMPLETED BY CLAIMANT - 1 - 1. 2. Social Security Number 3. Date (mm/dd/yyyy) 4. Mailing Address (Street or P.O. Box, City, State, Zip) 5. Telephone Number (include area code) 6. Claim Number 7. The claimant hereby petitions to re - open the above - captioned claim for the following reasons: 7a. To be examined by permanent partial disability/impairment rating due to: Aggravation and/or progression of condition or disability resulting from the compensable injury or occupational disease. Fact or factors pertaining to the disability or condition not previously considered by the OIC in previous findings. 8. Have you suffered from any other illness and/or injuries since the injury upon which this claim is based? Yes No If yes, specify the nature of the illness and/or injuries, the dates of the illnesses, and/or injuries, and list the name(s) and address(s) of the physician(s) who treated you. 9. Have you filed any other claim(s) If yes, please list all claim numbers and/or dates of injuries or occupational disease. 10. Have you drawn unemployment or wage replacement benefits since the injury or occupational disease covered by this claim? Yes No If yes, for what period? Dates: From: / / To: / / 11. Do you continue to work for the employer for whom you were working at the time of the injury or occupational disease? Yes No If no , please provide the name and address of current employer. Date: Revised 5 / 201 6 Claim R e - Opening Ap plication for Permanent Partial Disability Section I After completion, please forward this application for benefits and any supporting evidence to your private carrier/self - insured/TPA administering your W C ompensation c laim. American LegalNet, Inc. www.FormsWorkFlow.com SECTION II TO BE COMPLETED BY THE PHYSICIAN IN DETAIL AND A NARRATIVE REPORT ATTACHED IF NECESSARY - 2 - Revised 5 /201 6 1. Treating Physician for claim New Treating Physician 3. Were you the treating physician for this claim, or are you a new treating physician? 4. Date of examination upon which these findings are based 5. List the current diagnosis for which you are performing the impairment rating (include specific ICD 1 0 - CM codes and description), and indicate whether or not you are xx requesting a rating on a different body part. ng certified as having reached the xx maximum degree of medical improvement? Yes No If yes, list the physical findings that relate to the aggravation/progression of the injury or occupational disease. (Please provide a short n arrative.) Please submit the results: 8. Can the claimant work at his or her regular job, or can he or she be returned to light duty? Yes No If no, will the injured worker benefit from rehabilitation services? 9. Has the injured worker reached the maximum degree of medical improvement? Yes No 10. Using the Range - of - Motion model, provide tables and charts used to arrive at the degree of permanent partial disability in terms of whole person percentage. Please xx x apply Title 85 Rule 20 to the exam. 11. Please list any previous percentages given for the same body part, and indicate whether or not it should be subtracted from the impairment ra ting. Date Claim Re - Opening Application for Permanent Partial Disability Section II American LegalNet, Inc. www.FormsWorkFlow.com