APPLICATION TO REOPEN CLAIM Department of Labor & Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 VICTIM INFORMATION Complete your portion in FULL for prompt action DUE TO WORSENING OF CONDITION Claim number Important: Only use this form if your medical condition has worsened, and your claim has been closed for more than 90 days. 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. Please write your claim number above. You will receive information about your reopening application within 90 days of the Department's receipt of the reopening application. 2. Name changed since claim No closed? Yes If yes, list previous name 1. Name (first, middle, last) 4. Soc. Sec. No. (for ID only) 3. Home phone no. 6. Mailing address (if different than home address) 5. Present home address 7. City State 8. City ZIP ZIP State Address 8a. I prefer my correspondence go to my Representative. Name: 9. Date of original injury State ZIP 10. Employer at time of original injury / / 11. What are your present physical complaints? 12. Date claim closed 14. Full name of provider treating you at time of claim closure 13. Date condition became worse after claim closure? / / / / 15. What parts of your body are affected? 16. Have you had any new injuries or illnesses since Yes No the date of claim closure? 17. Did your condition worsen due to another injury or accident? Yes No If yes, explain. If yes, explain. 18. Have you received any medical treatment for this condition since claim closure? If yes, list name and address of treating provider(s). 19. Provider No 20. Provider Phone number Phone number Address Address City State 21. Have you applied for or are you receiving any of these benefits? (check all that apply) Unemployment Sick leave SSI/SSA Medicare Yes Public assistance Retirement benefits Disability insurance Worker compensation ZIP+4 City State ZIP+4 Any other Industrial Insurance compensation? (i.e., Longshore harbor workers, Jones Act, Railroad) If checked, explain. 22. Are you working? Yes No If no, Retired Why? Unable to work Laid off Quit 24. Present or last employer 23. Last date worked Phone number Address City State ZIP+4 25. Type of business 26. Your job title and duties 27. How long have you worked for this employer? NOTE: Persons making false statements in obtaining Crime Victims Compensation benefits are subject to civil and criminal penalties. I declare that these statement 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 Crime Victims Compensation Program. Today's date Dept. use only Victim's signature / / F800-031-000 application to reopen claim 2-08 X CONTINUE FOR PROVIDER'S INFORMATION American LegalNet, Inc. www.FormsWorkflow.com Claim number PROVIDER'S INFORMATION (complete form in FULL) Please complete this form and send it to the Crime Victims Compensation 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. 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 not attach a bill to this form. 1. Please describe patient's current symptoms. 2. What was the FIRST date you saw the patient for these symptoms after claim closure? / / 3. Are the symptoms the result of the covered injury? Yes No 4a. List physical or psychological examination in detail, including all objective findings referable to complaints and areas involved in your claim. If evaluating a mental condition, please give relationship of all symptoms to the covered injury. Is there a preexisting physical or psychological condition that will retard recovery? 4b. Upon what information did you rely to make the comparison to substantiate worsening? Provider at the time of claim closure Reviewed the previous medical file (check box) Contacted the previous provider Other: 5. Does the current condition prevent the patient from working? Yes No If yes, estimate number of days off work: 6. Beginning date of current disability / / 7a. Describe the physical limitations and/or restrictions preventing the patient from working. Please provide the basis for your opinion. 7b. Could the patient return to work with modified or different duties (light, sedentary work or transitional part time work)? 8. List all medical factors that might impede or influence the patient's recovery. 9. What is your specific curative treatment plan? Please include expected time for recovery and indicate when the patient may return to some form of work. 10. Diagnosis of condition found by examination. ICD Diagnosis Codes Phone no. Provider's name (type or print) Address Today's date / / City CVCP provider no. / NPI # State ZIP + 4 Provider's signature X Benefits may be delayed if this form is not filled out completely Please retain a copy of this reopening application for your records F800-031-000 application to reopen claim 2-08 American LegalNet, Inc. www.FormsWorkflow.com