State of New York WORKERS' COMPENSATION BOARD REQUEST FOR FURTHER ACTION BY CARRIER/EMPLOYERThis form is submitted by carrier self-insurer ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERSSEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO10. Continuing payments directed by the Board should be suspended as of pursuant to 12 NYCRR 300.23(b). (medical or payroll documentation supporting suspension required)Continuing payments directed by the Board should be reduced to /wk as of pursuant to 12 NYCRR 300.23(b). (medical or payroll documentation supporting reduction required)Payments should be modified as claimant is working at full or reduced earnings as of . (payroll documentation supporting modification required) Payments should be suspended as of as claimant has voluntarily removed him/herself from or is no longer attached to the labor market. (documentation supporting suspension required) Payments should be suspended as of because of disqualification pursuant to WCL 247 114-a. (list of documents or evidence to be produced required)Payment of benefits should be transferred to Special Funds pursuant to WCL 247 25-a. (documentation of a claim for compensation/ treatment more than 7 years after the injury/death and 3 years from the last payment of compensation required)Claimant's disability is now amenable to a facial award or schedule loss of use award. (medical documentation indicating permanency required)Claimant's disability is now amenable to a non-schedule award. (medical documentation indicating permanency required)Claimant has made an application to reopen a previously established claim seeking additional benefits, and pursuant to 12 NYCRR 300.22 the carrier contends (statement as to the carrier's position on the payment of further benefits required)Carrier requests transfer regarding Special Funds liability pursuant to WCL 247 25-a. Parties have entered into a stipulation. (Form C-300.5 or written stipulation required)Parties have reached an agreement and seek a Proposed Conciliation Decision. (Form C-312.5 or proposed findings required)Claimant has discontinued or settled a lawsuit pertaining to the accident/injury of this claim. (documents indicating discontinuance, settlement, or closing statement required)Carrier has new or requested documentation regarding (documents required)Other. (Explain fully in space provided below.) 1. WCB CASE NO. 3. CARRIER CODE W 2. CARRIER CASE NO. 5. DISTRICT OFFICE m md dy y 4. DATE OF INJURY ADDRESS TO WHICH NOTICES SHOULD BE SENT NAME 6. CLAIMANT 7. EMPLOYER 8. CARRIER 9. ATTORNEY / LICENSED REP. APT. NO. ATTY/REP ID NO. Check if new address: INSTRUCTIONS: The carrier/employer seeks Board action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the Board or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the Board's electronic file. This form must be mailed, faxed or e-mailed to the Workers' Compensation Board. (See mailing and e-mail filing address on reverse side.) A copy of this form and the attachments must be sent to the claimant and claimant's representative if one has been retained. A copy of this form and the attachments must also be sent to the health care provider if item a or b is checked.Compensation:Medical Issues:Other: CERTIFIED BY (Please Print Name) DATE PREPARED (mm/dd/yy) WCB ID NO. AREA CODETELEPHONE NUMBER I certify that this request for Board action is based upon reasonable grounds, and that this form with attachment(s) has been provided to the opposing party(ies). I also certify that (check one box below): **Document reference information (date, name/title, form ID): c. a. b. d. e. f. g. h. i. j.Opioid Weaning under Non-Acute Pain Guidelines. (medical documentation indicating weaning goals and recommended weaning program/resource is required) k. l. m. n. settlement of the issue(s) was reached (documentation required). no settlement of the issue(s) could be reached.RFA-2 (10-16)R I have discussed the issue(s) above with the opposing party(ies) or its representative(s). (give name of person contacted) (on date)and that (check one): I attempted to contact (give name) on (date) to discuss the issue(s) above, that I have waited a reasonable time for a response, but that no discussion was forthcoming. o. American LegalNet, Inc. www.FormsWorkFlow.com RFA-2 (10-16) ReverseTO THE CARRIER/EMPLOYERThis form may be filed by the insurance carrier or employer in a workers' compensation case when it wants the Workers' Compensation Board to take action in the case. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. A copy of this form and the attachments must also be sent to the claimant, and his/her representative, if any. ITEMS a and b replace Form C-22b. If item a or b is checked, a copy of this form and the attachments must also be filed with claimant's attending doctor. If you would like on-line access to the case, you can register for eCase using the registration instructions available on the Board website under the eCase link.TO THE CLAIMANT - Regarding Items a and bPlease read this notice and attachments carefully. If item a or b is checked, this notice means that your employer (if self-insured) or its insurance company wants to suspend or reduce your compensation payments, for the reason indicated.As explained above, your case may be scheduled for a hearing on this issue. Be sure to BE PRESENT, if you disagree with your employer or his/her insurance company. If you are NOT PRESENT, the W.C. Law Judge will make a decision based on available evidence. If your employer or his/her insurance company contends that your compensation payments should be suspended or reduced because your medical condition has improved (not because your earnings have increased), BRING TO YOUR HEARING THE MOST RECENT MEDICAL REPORT FROM YOUR DOCTOR THAT DESCRIBES YOUR CURRENT MEDICAL CONDITION.PARA EL RECLAMANTE - Respecto de los puntos a y b Lea atentamente esta notificaci363n y los documentos adjuntos. Si est341n marcados los puntos a o b, esta notificaci363n significa que el empleador (en caso de estar auto asegurado) o su compa361355a aseguradora, desea suspender o reducir los pagos de su indemnizaci363n, por el motivo que se indica. Tal como se explica anteriormente, es posible que se fije una fecha para una audiencia sobre su caso en relaci363n a este asunto. Aseg372rese de ESTAR PRESENTE, en caso de que usted est351 en desacuerdo con su empleador o su compa361355a aseguradora. Si usted NO EST301 PRESENTE, el juez que dirime sobre cuestiones laborales tomar341 una decisi363n a partir de la evidencia disponible. En caso de que su empleador o su compa361355a aseguradora aleguen que se deben suspender o reducir los pagos de su indemnizaci363n debido a una mejor355a de su condici363n m351dica (no debido a un aumento de sus ingresos), PRESENTE EN LA AUDIENCIA EL INFORME M311DICO M301S RECIENTE QUE DESCRIBA SU CONDICI323N M311DICA ACTUAL, ESCRITO POR SU M311DICO.Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to a material fact for the purpose of avoiding provision of any payment or benefit under this chapter shall be guilty of a felony.Regarding Items a and b - Board Rule 12 NYCRR 300.23This notice (items a and b) replaces Form C-22b for the purpose of notifying the Board of the carrier/employer's intention to reduce or suspend the claimant's payments in accordance with Board Rule 12 NYCRR 300.23. This notice may be filed in any case where there has been an award and a direction for continuation of payments and evidence is presented to support the suspension of payments or reduction in rate. The Board, upon receipt of this notice and attachments, may either schedule a WC LAW JUDGE HEARING on this issue within 20 days during any period in which regular hearings are scheduled, or refer