Nysca Workers' Compensation Complaint Form (Page 2 of 2) in pdf

Dear Patient

On Decem ber 1, 2010, the New York State W orkers’ Com pensation Board (W CB) im plem ented new regulatory

procedures designed, in theory, to guide a provider’s treatm ent of clinically necessary care and treatm ent of injured

workers through the adoption of m edical treatm ent guidelines. At the sam e tim e, the W CB adopted wholly new

processes for the adm inistration, adjudication and settlem ent of workers’ com pensation claim s and cases. In the

run-up to the adoption of the new regulations, m any questions were raised for which the W orkers’ Com pensation

Board had no specific or concrete answers. For exam ple, the m edical treatm ent guidelines im plem ented by the

Board were adopted without input from health care providers from the field and, m ore specifically, did not address

any instance where a patient m ay have a lingering or chronic care problem or issue. In addition, every case was to

be treated as new as of Decem ber 1, 2010 regardless of when the injury occurred or how the case had been

handled prior to Decem ber 1. To com pound m atters, all interested parties involved – the workers com pensation

board and its adm inistration, em ployers, workers’ com pensation insurance carriers, claim ant’s and claim ant

representatives and health care providers are interpreting the regulations differently and are im plem enting them in a

variety of ways that lack consistency and, in som e cases, com plete coherence.

Since these are wholly new processes that have been im plem ented by the Board, there are a lot of unsettled

problem areas between the different parties that ultim ately could have a negative or detrim ental affect on your care

and your workers’ com pensation claim and case.

As your health care provider, I would like to advocate for you to m ake sure you receive all the necessary care you

need and deserve. Consequently, I am asking you to help m e, help you.

The chiropractic profession is attem pting to collect and sort problem cases that have arisen in handling and

adm inistration of claim ants’ cases. To do this, however, we need your authorization to share som e basic

inform ation about your case with the New York State Chiropractic Association (NYCSA), prim arily:

the nature of

the com plaint involved in the adm inistrative or adjudication of your specific claim and case num ber;

a copy of the

original bill I subm itted to your em ployer or workers’ com pensation carrier on your behalf; and

a copy of the

Explanation of Benefits (EOB) that was received in return in response to the bill that was subm itted to your

insurance carrier. Outside of your first nam e and the first initial of your last nam e, no other personal inform ation

about you or your care will be shared with the state Association. The NYSCA is sim ply looking for patterns of

incorrect or inconsistent im plem entation of the new regulations in order to settle som e long-standing procedural

issues in the adm inistration of claim ant cases with the state W CB.

You are under no obligation to sign this statem ent or this form ; but then, neither the state Association nor I would be

in a position to help you if any particular issue arose, that when com bined with other, sim ilar cases could

dem onstrate a m isapplication of the regulation and its im plem entation. If you agreed to help, however, just com plete

and sign the statem ent below. A copy of this authorization form will be placed in your W C file and will be valid for a

period of one-year from the date you sign below. In addition, you m ay revoke this authorization at any tim e in

writing. If you have any other com m ents or questions relative to this authorization, please let m e know.

Patient’s Nam e: ________________________________________

W CB Case #: _______________

(Please Print)

Patient’s Signature: _____________________________________

Date: ______________________

Nysca Workers' Compensation Complaint Form Page 2