Transcription of Form C-27 - New York State Workers' …
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Form C-27 - New York State Workers' …
Typed or Printed Name of Attending )Countyof),beingdulysworn,deposesandsays :That(s)heisthe,dulylicensedintheStateof NewYork,whosubscribedtotheabove(orattach ed)report;andthat(s)hehasreadthesameandk nowsthecontentsthereof;thatthesameistrue totheknowledgeofdeponent,exceptastothema ttersstatedtobeoninformationandbelief,an dastothosematters(s) of New york WORKERS' compensation BOARDTHIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT TYPE OF DOCTORPHYSICIANCHIROPRACTORPODIATRISTPSY CHOLOGISTMEDICAL PROOF OF CHANGE IN CONDITION IN SUPPORT OF APPLICATION FOR REOPENING OF CLAIM FOR WORKERS' compensation , VOLUNTEER FIRE FIGHTERS' OR VOLUNTEER AMBULANCE WORKERS' BENEFITSThis report must be signed personally by the attending doctor or by some other doctor having knowledge of the facts.
HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers …
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