Dept of Labor and Industries State Fund PO Box 44291 Olympia WA 98504-4291 Fax: 360-902-6100 Dept of Labor and Industries Self-Insurance PO Box 44892 Olympia WA 98504-4892 Fax: 360-902-6900 Application to Reopen Claim Claim number Due to Worsening of Condition Worker Information Complete your portion in full for prompt action. Use this form only if your medical condition has worsened and your claim has been closed for more than 60 days. If you have had a new injury at work, complete a new Report of Industrial Injury or Occupational Disease form. 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. You will receive information about your reopening application within 90 days of the Department's receipt of the reopening application. Name (First, Middle, Last) Home phone number Current home address City State Zip Code Has your name changed since your claim closed? No Yes If yes, list previous name: Social Security Number (for ID only) Mailing address (if different from home address) City State Zip Code I prefer my correspondence go to my representative (give name and mailing address of representative) Date of original injury Employer at the time of the original injury What parts of your body are affected by this injury/disease? What are your present physical complaints? Did your condition worsen due to another injury/accident either on or off the job? Date claim closed Full name of doctor treating you at time of claim closure Date condition became worse after claim closure Have you had any new injuries/illnesses since the date of claim closure? No Yes If yes, explain No Yes If yes, explain Have you received any medical treatment for this condition since claim closure? Doctor name City Are you working? State Phone number Zip Code No doctor(s). City Yes If yes, list name(s) and address(es) of treating Phone number State Doctor name Zip Code Yes No If no, why? Retired Unable to work Laid off Quit Last date worked: Have you applied for or are you receiving any of the benefits listed below? Unemployment Sick leave Public assistance Retirement benefits Disability insurance Any other industrial insurance compensation? (i.e. Longshore and Harbor Workers, Jones Act, Railroad) Present or last employer Address City Type of business Your job title and duties What other employers and job titles have you had since your claim was closed? State How long have you worked for this employer? Phone number Zip Code Note: Person making false statement in obtaining industrial service benefits are subject to civil and criminal penalties. I declare that these statements 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 and Industries and/or the Self-Insured Employer. Claimant's signature F242-079-000 Application to Reopen Claim Due to Worsening of Condition 03-2014 Date American LegalNet, Inc. www.FormsWorkFlow.com Provider Information Claim number Please complete this form and send it to the Claims Program or the Self Insurance Program. It will enable us to determine if the current medical condition is due to a worsening of a previous 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. We cannot pay you for services related to the reopening of the claim if you are not participating in the L&I Medical Provider Network. If you are a part of the L&I Medical Provider Network, 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 no attach a bill to this form. Please describe patient's current symptoms. What was the FIRST date you saw the patient for these symptoms after claim closure? Are the symptoms the result of the covered injury? Yes No 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. Upon what information did you rely to make comparison to substantiate worsening? Check appropriate box. Provider at the time of claim closure Reviewed the previous medical file Contacted the previous provider Other: Does the current condition prevent the patient from working? No Yes If yes, estimate number of days off work: Beginning date of current disability Describe the physical limitations and/or restrictions preventing the patient from working. Please provide the basis for your opinion. Could the patient return to work with modified or different duties (i.e. light, sedentary work or transitional part time work)? List all medical factors that might impede or influence the patient's recovery. What is your specific curative treatment plan? Please include expected recovery time and indicate when the patient may return to some form of work. Diagnosis of condition found by examination. ICD Codes. Provider name (please print) Provider address City State Zip Code Provider number Provider phone number Provider's signature and date Benefits may be delayed if this form is not filled out completely. Please retain a copy of this reopening application for your records. F242-079-000 Application to Reopen Claim Due to Worsening of Condition 03-2014 American LegalNet, Inc. www.FormsWorkFlow.com