STATE OF NEW YORK WORKERS' COMPENSATION BOARD PROOF OF DEATH (By Physician Last in Attendance on Deceased) This report must be signed by the physician last in attendance on the deceased in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases. In hospital cases it may be signed by a licensed physician who is a member of the attending staff of the hospital to whom treatment of the case was assigned. File the signed original of this report directly 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/COMPUTER PREPARATION IS STRONGLY RECOMMENDED 1. WCB Case Number (If Known) 2. Carrier Case Number (If Known) 3.Date of Accident or Injury and Time 4. Address Where Accident or Injury Occurred NAME 5. DECEASED PERSON 6. EMPLOYER * 7. INSURANCE CARRIER 8. HOSPITAL (If any) 9. NEAREST RELATIVE Relationship Date of Birth ADDRESS Soc. Sec. Number * If claim is made that death resulted from injury sustained in the performance of assigned duty as a Volunteer Firefighter or Volunteer Ambulance Worker show as EMPLOYER the city, town, village or district or ambulance company against which claim is made and enter "X" here: VF/VAW 10. (a) Date of death___________________(b)Place of death (Give street number, city, state):____________________________________ 11. Decedent's marital status at time of death (Single, married, widowed, divorced):________________________________________ 12. (a) How long have you been medical advisor of deceased?_________________ (b) Date of your first visit:__________________ (c) Date of last visit:__________________ (d) Was deceased attended by any other physician during last illness?_______ If so, give name and address of other physician:_____________________________________________________________________ _______________________________________________________________________________________________________ 13. State in patient's own words how the accident or injury occurred:____________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 14. Give complete and accurate description of nature and extent of injury, as you found it and subsequent examinations:___________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 15. State the direct cause of death________________________________________________________________________________ (a) In your opinion was the accident or injury as above described a cause either directly or indirectly of the death?____________ C-64 (1-11) SEE REVERSE SIDE American LegalNet, Inc. www.FormsWorkFlow.com 15. (b) Describe contributory causes, if any:_______________________________________________________________________ ________________________________________________________________________________________________________ 16. Was coroner's inquest held?_______If so, give coroner's name and address:__________________________________________ ________________________________________________________________________________________________________ I state that I am a physician duly licensed to practice medicine in the State of New York. W.C.B. Rating Code____________________________________ _____________________________________________________ (Written Signature of Attending Physician) W.C.B. AuthorizationNumber_____________________________ Address_____________________________________________ Dated_________________________________________________ ____________________________________________________ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. 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. Reports should be sent directly to the Workers' Compensation Board at the address listed below: NYS Workers' Compensation Board Centralized Mailing PO Box 5205 Binghamton, NY 13902-5205 Statewide Fax Line: 877-533-0337 THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-64 (1-11) Reverse www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com