INSTRUCTIONS FOR COMPLETING WORK INJURY SUPPLEM ENTAL BENEFIT FUND BARRED CLAIM Pursuant to the mandatory reporting requirements for the Department of Workforce Development, Division of 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 this completed claim form must be filed with a WKC - 7 Hearing Application for all barred traumatic or occupational injury claims made against the Work Injury Supplemental Benefit Fund. It can b e mailed to Building, 201 East Washington Ave., Room C100, Madison, WI). If at any time you need more space than is provided on the claim form, u se a separate sheet of paper to provide the required information. To avoid confusion, note on the claim form that the required information is on an attached the additi onal sheet(s). Specific instructions follow. Boxes 1 - 9 - Employee Information The employee information sections should be completed with informa tion about the injured worker. Please ensure that questions 8 and 9 are filled out. Box 10 - Date of Injury Example: 7/15/2009. In the case of traumatic injuries, this would be the actual date of the accident or incident. If there is more than one date of injury for a particular employer, indicate all dates in the space provided, or on an addition al sheet if ne cessary. In the case of occupational hearing loss, the injury date would be the date of either : (a) transfer to non - noisy employment, (b) last day worked before retiring, (c) termination of employer - employee relationship, or (d) layoff i f at least 6 month s. In the case of occupational disability exclusive of hearing loss; the date of injury would be the date of disability or if disability occurs after cessation of employment, the last day of work for the last employer whose employment caused disability. Box 11 - CMS Date of Incident (DOI) Example: 6/15/1982. Per the reporting requirements as laid out by the Centers for Medicare & Medicaid Services (CMS) Non - Group Health Plan User Guide v3.2: (1) for traumatic injuries the date of incident is the date of the injury ; (2) for exposure claims ( such as occupational hearing loss and diseases such as asbestosis) the date o f incident is the date of first exposure ; (3) for claims involving implants it is the date of the implant (or date of the first implant if the re are multiple implants ); (4) for cumulative t raumatic injuries (such as carpa l tunnel and certain back injuries) the date of incident is the earlier of the date that treatment for any manifestation of the cumulative injury began, when such treatment prec eded formal diagnosis ; or the first date that formal diagnosis was made by any medical practitioner. Box 12 - Injury Description Describe how the injury happened, the nature of the injury and the part -- or parts - - of the body injured. Box 13 - Surgeries d ue to the alleged injury List any surgeries you had, and the dates that you had them, as a result of the alleged injury. Box 14 - Diagnosis or Nature of Illness or Injury ICD - 9 /ICD - 10 - CM Codes If multiple body parts are affected , multiple codes may be nec essary, but it is not necessary to use all eight fields. No diagnosis code. * You may also attach a 1500 Health Insurance Claim Form related to the inju ry in lieu of entering codes. Box 15 - ompensation benefits , list the name of the insurance carrier or self - insure d employer who paid them. Also list the d ate that you received your last payment of benefits. Boxes 16 - 17 - Sign and date the claim form. Who can I contact for more information regarding the WISBF Barred Claim Form? mpensation Division. Our mailing address is P.O. Box 7901, Madison, Wisconsin 53707. Our telephone number is (608) 266 - 1340 or you can rea ch us by fax at (608) 267 - 0394 *If the CMS DOI is prior to October 1, 2015 then you may use an ICD - 9 CM code. If the C MS DOI is on or after October 1, 2015 you must use an ICD - 10 CM code . American LegalNet, Inc. www.FormsWorkFlow.com Department of Workforce Development 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madi s on, WI 53707 Telephone: (608) 266 - 1340 Fax: (608) 267 - 0394 http://dwd.wisconsin.gov/wc e - mail: DWDDWC@dwd.wisconsin.gov Pursuant to the Responsible Reporting Entity under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 t his completed claim form must be filed with an Application for Hearing for all barred traumatic or occupational injury claims made against the Work In jury Supplemental Benefit Fund. It can be mail - 7901 (or filed in person at the State Office Building, 201 East Washington Ave., Room C100, Madison, WI). * Provision of your Social Security Number (SSN) is mandatory under Sectio n 111 of Medicare, Medicaid and SCHIP Extension Act 2007 (42 U.S.C. s. 1395y (b) (7) & (8)) and will be used to identify the claimant. Failure to provide it may result in penalties or delayed payment of benefits. Personal information you provide may be use d for secondary purposes [Privacy Law, s. 15.04(1)(m) , Wisconsin Statutes ]. 1. Employee Name 2. Employee Social Security Number * 3.Date of Birth 4.Age 5.Employee Mailing Address 6. Employee Telephone Number (include area code) 7. Sex Male Female 8.Have You Applied For or Are You Receiving Social Security Benefits? Yes No 9.Have You Applied For or Are You Covered Under Medicare? Yes No If Y es, Medicare Claim Number : 10. Date of Injury 11. Date of Incident as defined by the Centers for Medicare & Medicaid Services (see the i nstructions for box 11) 12. Description of the nature of the injury, including parts of the body affected and the cause of the injury 13.Surgeries you had due to the alleged injury 1. Date: Name of Doctor 2. Date: Name of Doctor 3. Date: Name of Doctor 14. Diagnosis or Nature of Illness or Injury ICD - 9 /ICD - 10 - CM Codes. Please see the instructions. You may also attach a 1500 Health Insurance Claim Form related to the injury in lieu of entering codes. 1. . 2 . . 3. . 4. . 5. . 6. . 7. . 8. . 15. Yes No er or self-insured employer:Date of last payment of benefits: I declare that to the best of my knowledge and belief, the information contained in this claim form is true, correct and complete and reflec ts actual events that occurred. 16.Applicant Signature 17.Date Signed WKC - 16804 - E (R . 07 /201 7 ) WORK INJURY SUPPLEMENTAL BENEFIT FUND BARRED CLAIM American LegalNet, Inc. www.FormsWorkFlow.com