Request For Assistance by Injured Worker

Request for Assistance by Injured Worker

ERFA-1W

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

ATTENTION: Please read these Instructions before completing and submitting the ERFA-1W.

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

This form is not to be used to report an injury. To file a claim, use Form C-3.

Required items are indicated by an *.

Case Information

* Date of Injury/Illness:

WCB Case Number:

Injured Worker Information

* Last Name: * First Name: MI:

* Mailing Address: Check if new address

Line 2:

* City: State: Zip Code: Country:

Daytime Phone #:

Email Address:

Social Security #:

* Date of Birth:

* Gender:

M F X

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Employer Information

* Employer Name:

Mailing Address:

Line 2:

City: State: Zip Code: Country:

Employer Phone #

Federal Tax ID #:

The Tax ID # is the (select one):

SSN EIN

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REASON FOR THIS REQUEST

INSTRUCTIONS: Check all boxes that apply. Be sure to attach additional forms, medical reports, letters, etc. as required for each checkbox. If the additional information was already submitted do not attach it, but try to identify it in the space at the bottom of this form** by giving the form number or title and the date it was submitted to the Board.

Compensation Payments:

a. I am not working as of and not receiving payments.

(Medical documentation indicating disability required.)

Check all that apply:

I have filed a claim for a work related injury.

My employer is not paying my wages.

My claim has not been denied.

I have not received a decision barring me from compensation.

I have attempted to resolve the issue with the insurer.

b. My payments have been stopped or reduced.

c. I have returned to work as of at full pay.

d. I am making less money than I was before I got hurt.

(Attach current pay stub and medical reports from your doctor.)

e. I had two or more employers on the date of accident/injury (concurrent employment).

(Attach weekly gross pay before your injury and statement from second employer regarding lost time.)

f. I was released from incarceration on and am not receiving payments.

(Attach medical report that shows a medical disability and release from custody papers.)

g. I have not been paid as directed in the decision filed on

Medical Issues:

h. My Prior Authorization Request (PAR) was denied by the insurer.

(attach PAR denial) Review by WCB Adjudication can only be requested if:

Denial category was Administrative or No Jurisdiction.

(Attach any documents that show why the denial was incorrect.)

MTG Special Services or MTG Variance PAR was denied for Medical reasons.

Non-MTG over $1,000 was granted in part.

i. My Medication, Durable Medical Equipment, MTG Variance or MTG Special Services PAR was denied or granted in part by the Medical Director's Office.

(Attach "Notice of Resolution" regarding treatment.)

j. My disability is now permanent.

(Attach Form C-4.3, Doctor's Report Of MMI/Permanent Impairment.)

Check this box if you were under 25 years of age at time of accident.

k. My medical condition has changed.

(Attach medical forms.)

l. My request for medical and transportation reimbursement was denied or has not been addressed.

(Attach receipts and Form C-257.)

Other Issues:

m. I have new information and/or information requested by the Board regarding:

(Attach documents.)

(Attach documents)

n. Other

(Explain in the space provided below)

** Document reference information (date, name/title, form ID):

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Select File(s) to Attach

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

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State of New York - Workers' Compensation Board

Compensation Payments:

Medical Issues:

Other Issues:

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