Explain HOW and WHEN your hearing loss was caused by exposure to noise at work:
Date on which you were made aware you have suffered noise-induced hearing loss: / /
Daily rate of pay on the last day you were exposed to noise at work: $
LIST ALL DOCTORS YOU HAVE SEEN FOR HEARING LOSS OR PROBLEMS RELATED TO YOUR EARS – USE SEPARATE SHEET IF NECESSARY
I certify that the above is true and correct to the best of my knowledge. I am aware the law provides for severe penalties if I knowingly and with fraudulent intent withhold facts or make false statements in order to obtain or increase benefits to which I am not entitled. By signing this application, I hereby authorize any physician, chiropractor, surgeon, practitioner or other healthcare provider, any hospital, including Veterans’ Administration or governmental hospital, and medical service organization, any insurance company, any law enforcement or military agency, any government benefit agency including the Social Security Administration, or any other institution or organization to release to each other, any medical or other information, including benefits paid or payable, pertinent to this injury or disease, except information relative to the diagnosis, treatment and/or counseling for HIV/AIDS, psychological conditions, and/or alcohol or substance abuse, for which I must give specific authorization. A Photostat of this authorization shall be as valid as the original.
Only audiometric test results obtained by an audiologist having a certificate of clinical competence in audiology (CCCA) or a West Virginia audiology licensure are acceptable for purpose of awarding compensation.
PTA/SRT within 10 dB? Y N
Ascending/Descending thresholds with 5 dB? Y N
Reliability rated GOOD? Y N
Section II – Part B MUST BE COMPLETED BY E.N.T., OTOLOGIST OR OTOLARYNGOLOGIST
EMPLOYMENT HISTORY: LIST ALL EMPLOYMENT, BEGINNING WITH THE MOST RECENT – USE SEPARATE SHEET IF NECESSARY
Description of Duties/Nature of Noise Exposure:
Chief complaints/symptoms as related to hearing loss:
ICD9-CM Diagnosis Code(s):
List any pre-existing conditions which may have attributed to hearing loss:
Section II – Part B (Continued) MUST BE COMPLETED BY E.N.T., OTOLOGIST OR OTOLARYNGOLOGIST
Does the claimant have a bilateral sensorineural hearing loss directly attributable to or perceptibly aggravated by industrial noise exposure in the
course of and resulting from his/her employment? Y N If yes, please answer A and B below.
A. Recommended percentage of impairment due to work-related noise exposure:
B. Explain and qualify:
Do you recommend additional treatment or correctional devices? Y N If yes, explain:
Date you first informed the injured worker of the diagnosis of Noise-Induced Hearing Loss: / /
Physician’s Name and Address:
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I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge I have been informed of my responsibilities under West Virginia’s Workers’ Compensation Law and agree to abide by such in the administration of services provided thereunder. I understand the submission of false statements or billing may result in prosecution under state and federal law. I further agree to release any office notes/test results immediately to the employer or their representative.