Fill and Sign the Claimant Action Form

PREPARED BY (Please Print Name)      Yes No Yes No                                                                                                                                                                 IF CLAIMANT'S ADDRESS SHOWN ABOVE IS NEW. a. requests referral for Administrative b. he/she has had a change of medical condition. j. he/she now has medical evidence of permanency. k. new or requested evidence is now available. c. he/she is not working and not receiving payments. d. his/her payments have been suspended/reduced. e. he/she has returned to work at full wages. f. he/she is working at reduced earnings. o. other (explain fully in the space provided below.)             R claimant State of New York WORKERS' COMPENSATION BOARD CLAIMANT'S REQUEST FOR FURTHER ACTION ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 3. CARRIER CODE 4. DATE OF INJURY 5. SOCIAL SECURITY NO. 6. DISTRICT OFFICE 1. WCB CASE NO. 2. CARRIER CASE NO. m m d d y y NAME ADDRESS TO WHICH NOTICES SHOULD BE SENT APT. NO. 7. CLAIMANT 8. EMPLOYER 9. CARRIER 10. ATTORNEY OR ATTY/REP I.D. NO. LICENSED REP. CHECK HERE REASON FOR THIS REQUEST (Check all that apply - use item o. for explanation or additional information - see reverse side for further explanation) 10. CLAIMANT Determination/Conciliation/Hearing, as appropriate, because (please check the appropriate boxes below): h. a request for medical treatment was denied or not addressed. I. a request for medical and transportation reimbursement was denied. IF THIS BOX IS CHECKED ATTACH MEDICAL REPORT IF REPORT WASPREVIOUSLY SUBMITTED IDENTIFY IT IN ITEM o. BELOW BY DATE,DOCTOR'S NAME AND FORM ID, IF ANY. m. he/she has discontinued or settled a lawsuit pertaining to this accident/injury. n. claimant has a change of address (please provide new address in 6., above) g. he/she has not been paid as directed in a notice of decision. ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD. IF MEDICAL EVIDENCE WAS PREVIOUSLY SUBMITTED,IDENTIFY IT BY DATE, DOCTOR'S NAME AND FORM ID, IF ANY, IN THE SPACE PROVIDED ABOVE. 11. Have the above issues been resolved by agreement? If Yes, please attach documentation. If No, have you attempted to resolve the issue(s) checked above with the other parties? I hereby certify that a copy of this form with attachment(s) was submitted to the other party(ies) in this case in accordance with the instructions above. DATE PREPARED MM DD YY AREA CODE TELEPHONE NUMBER This form is submitted by claimant's representative RFA-1 (8-03) SEE IMPORTANT INFORMATION ON REVERSE - VEA INFORMACION IMPORTANTE AL DORSO