Form 827 - Worker'S And Health Care Provider'S Report For Workers' Compensation Claims
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4Worker’s and Health Care Provider’s Report for Workers’ Compensation Claim, Form 827
Instructions and definitions
Ask the worker to complete this form ONLY in the following circumstances:
• First report of injury or disease
• Request for acceptance of a new or omitted medical condition
“Omitted” refers to a condition the worker thinks should have been included among the conditions
accepted by the insurer.
• Report of aggravation of original injury
“Aggravation” means the actual worsening of an accepted condition resulting from the original injury.
• Notice of change of attending physician or nurse practitioner
This means the new provider will be primarily responsible for treatment. Being primarily responsible does
NOT include:
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Treatment on an emergency basis
•
Treatment on an “on-call” basis
•
Consulting
•
Specialist care (unless the specialist assumes complete control of care)
•
Exams done at the request of the insurer or the Workers’ Compensation Division
If the worker completes and signs Form 827, give the worker copies of Form 827 and Form 3283
(included with this packet) immediately.
Do NOT ask the worker to complete this form for the following:
• Progress report
• Closing report
• Palliative care request
Palliative care is care that makes the worker feel better but does not cure an unwanted condition. The
worker must be in the workforce or in a vocational program to be eligible for palliative care. The following
are not palliative care:
•
Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them
•
Diagnostic services
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Life-preserving treatments
•
Curative care to stabilize an acute waxing and waning of symptoms
•
Services to a permanently and totally disabled worker
When requesting palliative care approval from the insurer, include the following in your request:
•
Who will provide the care
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Modalities ordered, including frequency and duration
•
How the need for care is related to the accepted conditions
•
How the care will enable the worker to continue current work or vocational training
For these reports, you have the option of filing Form 827, submitting chart notes, or submitting a
report that includes data gathered on Form 827.
“Regular work” under “Work ability status” means the job the worker held at the time of injury.
If you have questions about completion of Form 827, please contact a benefit consultant at 800-452-0288.
827
440-827 (04/10/DCBS/WCD/WEB)
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