BI-1HL 12/07 Employee and Physician's Report of Occupational Hearing Loss Return completed form to: BrickStreet Mutual Insurance Occupational Hearing Loss Unit P.O. Box 3151 Charleston, WV 25322-3151 PLEASE TYPE OR PRINT WITH A BLACK OR BLUE BALLPOINT PEN 1. Claimant’s Name (First, Middle, Last) 2. Social Security Number 3. Mailing Address 4. Telephone Number 5. Date of Birth (Month, Day, Year) 10. Check One: 6. Martial Status: Single Married Widowed 8. County of Residence 7. Gender: Female Male Still Working – Date last exposed to loud nose on job: Not Working – Date Last Worked: 11. Have you ever filed a hearing loss claim? Yes / No / 9. Daily rate of pay on date last exposed to loud noise on job: / / Reason no longer working: Claim Number, if available: 12. Employment History: List all employment beginning with most recent (Attach a separate page if necessary). SECTION I – TO BE COMPLETED BY CLAIMANT Employer’s Name and Address From To Description of Duties 13. Explain HOW and WHEN your hearing loss was caused by industrial noise exposure 14. Date you were made aware you have suffered a noise induced hearing loss: / / 15. List ALL doctors you have seen for hearing loss or problems related to your ears. Attach a separate page is necessary. Name Address Date Seen I certify the statements and answers set forth in this section are true and correct to the best of my knowledge and belief. I am aware the law, specifically WV Code § 61-3-24f, provides for severe penalties if I knowingly and with fraudulent intent withhold facts or make false statements in order to obtain or increase benefits to which I am not entitled. By signing this application, I authorize any physician to release to or orally discuss with, either my employer or an authorized agent of BrickStreet Insurance, any medical records pertaining to the occupational injury or illness for which I am claiming benefits and any prior injury to or disease to the portion of my body for which I am alleging a medical impairment. I acknowledge the provisions of WV Code § 23-4-7 providing authorization for release of medical information by a physician to my employer or employer representative. Claimant’s Signature: Date: American LegalNet, Inc. www.FormsWorkflow.com SECTION II PART A – TO BE COMPLETED BY AUDIOLOGIST Only audiometric test results obtained by an audiologist having a certificate of clinical competence in audiology (CCC-A) or a West Virginia audiology licensure are acceptable for purpose of awarding compensation. For BrickStreet Use Only SECTION II PART B – TO BE COMPLETED BY AN ENT, AN OTOLOGIST OR AN OTOLARYNGOLOGIST BODY: A203 SOURCE: I-6 NATURE: G-2 For Audiology Verificaion PTA/SRT within 10 db? Yes No Ascending / Descending thresholds within 5db? Yes No Yes No Reliability rated good? TYPE: D-4 If this information is not provided by an ENT, an Otologist or an Otolaryngologist, BrickStreet Insurance will not consider it in the compensability determination. 1. Chief complaints / symptoms as related to hearing loss 2. Employment History: List all employment beginning with most recent. Attach a separate page if necessary. Employer’s Name and Address From To Description of Duties 3. Diagnosis Code (ICD9-CM) Hearing Protection (Yes / No) Medical History 4. List any pre-existing conditions that may have contributed to hearing loss 5. Examination Results 6. Does the claimant have a bilateral sensorineural hearing loss directly attributable to or perceptibly aggravated by industrial noise exposure in the course of and resulting from Yes No If yes, please answer A and B below. his/her employment? A. Recommended percentage of impairment due to work-related noise exposure: B. Explain and qualify: 7. Is further testing recommended? Yes No If yes, indicate type of testing. 8. Do you recommend additional treatment or correctional devices? Yes No If yes, explain. 9. Date you first informed the injured worker of the diagnosis of Noise-Induced Hearing Loss: / / 10. Physician’s Name and Address: 11. Physician’s Telephone Number 12. Physician’s FEIN I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically WV Code § 61-3-24g, provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge my contractual obligations to BrickStreet Insurance and agree to release any office notes/test results immediately to BrickStreet Insurance. Physician’s Signature Date Please make copies of this form for the claimant, for your records and send the original to BrickStreet Insurance. American LegalNet, Inc. www.FormsWorkflow.com