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The RFA-1W form serves as a crucial tool for injured workers seeking assistance in navigating the complexities of their workers' compensation claims. This form comes into play when there are various requests or issues that need to be addressed by the Workers' Compensation Board. Whether you're facing complications with medical treatment approvals, experiencing delays in compensation payments, or updating your situation due to a permanent disability, the RFA-1W guides you through articulating these challenges clearly. It allows you to indicate changes in your medical condition, outline issues related to medical and transportation reimbursements, and add any new information pertinent to your case. Additionally, you're invited to highlight other concerns that may affect your claim. With detailed instructions, this form empowers you to ensure that the Board receives all necessary documentation, such as medical reports and denial letters. Filling it out accurately not only helps streamline the process but also ensures that you receive the assistance and support needed during your recovery journey.
Rfa 1W Example
j. My medical condition has changed. Attach medical forms.
k. My request for medical and transportation reimbursement was denied or has not been addressed.
Other Issues:
l. I have new information and/or information requested by the Board regarding (Attach documents):
m. Other (Explain in the space provided below):
**Document reference information (date, name/title, form ID): Injured Worker Signature:
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 request for medical treatment was denied or has not been addressed. Attach denial letter.
i. My disability is now permanent. Attach medical 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.
f. I was released from incarceration on
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. and am not receiving payments.
REQUEST FOR ASSISTANCE BY INJURED WORKER
This form is not to be used to report an injury. To file a claim, use Form
Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS |
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Date of Injury/Illness: |
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WCB Case #: |
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Injured Worker Information |
Check if new address |
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Last Name: |
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First Name: |
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Mailing Address: |
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Line 2: |
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City: |
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Country: USA |
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Daytime phone #: |
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Email Address: |
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Social Security #: |
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Date of Birth: |
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Gender: |
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Employer Information
Employer Name: |
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Mailing Address: |
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Country: USA |
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Employer Phone: |
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Federal Tax ID #: |
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The Tax ID # is the (check one): |
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EIN
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. Sign and date the form below.
Compensation Payments:
a. I am not working as of |
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and not receiving payments. Medical documentation indicating disability required. |
Check all that apply: |
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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 |
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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.
Attach receipts and Form
Date:
This form and any attachments must be mailed, faxed or emailed to the Workers' Compensation Board.
To the Injured Worker - General Information On Using This Form
You may file this form
Complete the identifying information at the top of Form
Workers' Compensation Board
PO Box 5205
Binghamton, NY
Address for Email Filing: wcbclaimsfiling@wcb.ny.gov
Statewide Fax Line: (877)
The Board will contact you and all parties when it takes action on your claim.
*After each check box you will see the information needed in bold letters. For example, if you are letting the Board know that your disability is now permanent (box i), the information required is Form
YOU MUST SEND A COPY OF THIS FORM TO THE INSURER(S), OR DIRECTLY TO THE EMPLOYER OR ITS THIRD PARTY ADMINISTRATOR IF THE EMPLOYER IS
If you have any other concerns, you may contact the Board's ADVOCATE FOR INJURED WORKERS at (800)
You have the right to legal representation. A lawyer cannot charge you directly for representation in a workers' compensation claim. If there is an award in your claim, any legal fee request must be approved by the Board and will be deducted from the award to you by the insurer and paid directly to the lawyer.
Medical Treatment - In addition to medical services of less than $1000.00 in value, most medical services covered by the Medical Treatment Guidelines (regardless of the cost) do not require medical authorization. For these types of services, the Health Provider may provide treatment and bill the insurer. If there is no response within 45 days of receipt of the bill, the Health Provider may file for an administrative award on Form
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO, OR BY AN INSURER, OR SELF INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article
Form Characteristics
| Fact Name | Details |
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| Form Title | The RFA-1W form is titled "Request for Assistance by Injured Worker." It is used to alert the Workers' Compensation Board about various issues related to a worker's claim. |
| Purpose | This form serves multiple purposes, including notifying the Board of medical treatment denial, compensation payment issues, and changes in an injured worker's condition. |
| Submission Instructions | The completed form must be sent to the Workers' Compensation Board via mail, fax, or email. Specific contact information is provided within the form documentation. |
| Attachments Required | When submitting the form, injured workers must include certain attachments, such as medical reports and denial letters, based on the selected checkboxes on the form. |
| Eligibility | The form is intended for injured workers who are experiencing issues related to their workers' compensation claims, not for reporting new injuries. |
| Governing Laws | The use and requirements of the RFA-1W form are governed by New York Workers' Compensation Law, specifically sections governing claims administration and personal privacy. |
| Required Information | Injured workers must provide important personal information, including their name, mailing address, contact information, and details about their injury or illness on this form. |
| Privacy Protections | The Board is committed to protecting personal information as per the New York Personal Privacy Protection Law and the Federal Privacy Act of 1974. |
| Legal Representation Rights | Injured workers have the right to legal representation for their claims. Any legal fees must be approved by the Board if there is an award in the claim. |
Guidelines on Utilizing Rfa 1W
Once you have collected all necessary documents and information, you can start filling out the RFA-1W form. Follow these steps carefully to ensure everything is completed correctly.
- Provide the date of your injury/illness and your WCB case number at the top of the form.
- Fill in your personal details:
- Last Name
- First Name
- Middle Initial
- Mailing Address
- City
- State
- Zip Code
- Country
- Daytime Phone Number
- Email Address
- Social Security Number
- Date of Birth
- Gender (check either Male or Female)
- Complete your employer's information:
- Employer Name
- Employer Mailing Address
- City
- State
- Zip Code
- Country
- Employer Phone Number
- Federal Tax ID Number (check either SSN or EIN)
- In the Reason for this Request section, check all applicable boxes.
- If additional documentation is required for the selected options, attach those documents.
- If you have already submitted some of the requested documentation, note it in the space provided at the bottom of the form, including the form number or title and the submission date.
- Sign and date the form.
After completing the form, it must be sent to the Workers' Compensation Board. Make sure to include all attachments as directed. You can mail, fax, or email your submission. Once received, the Board will follow up on your request.
What You Should Know About This Form
What is the purpose of the RFA-1W form?
The RFA-1W form is designed for injured workers in New York seeking assistance from the Workers’ Compensation Board. It allows individuals to alert the Board about various issues affecting their claims, such as payment problems or medical treatment denials. By completing this form, workers can request specific actions related to their compensation or provide necessary information that may impact their cases.
Who should use the RFA-1W form?
This form is intended for workers who have filed a workers' compensation claim and are experiencing difficulties. If you have ongoing issues such as delayed payments, denials for medical care, or changes in your medical condition, this form will help you communicate with the Board effectively.
Can I attach additional documents to the RFA-1W form?
Yes, attaching relevant documents is crucial. If your situation involves issues like a denied medical request or proof of your changed medical condition, you should include those documents when submitting the RFA-1W form. Ensure you read the instructions carefully to know exactly what is required for each checkbox you select.
What happens after I submit the RFA-1W form?
Once submitted, the Workers' Compensation Board will review your form and any attachments. They will then take appropriate action regarding your claim and will reach out to notify you and any other relevant parties about their decision. This communication ensures that you remain informed throughout the process.
What if my medical condition has changed, and I have not reported it?
If your medical condition has changed, it is important to report this information to the Board using the RFA-1W form. You must attach supporting medical documents that clearly outline the changes. Reporting this promptly helps ensure that you receive appropriate care and support in a timely manner.
Is there a way to follow up on my claim once I submit the form?
Yes, you can track the status of your claim online through the Workers' Compensation Board's eCase system. Registration instructions are available on the Board’s website. This feature allows you to stay informed about your claim’s progress and any necessary actions you may need to take.
What if I have questions or need assistance while filling out the RFA-1W form?
If you have questions or require assistance with the RFA-1W form, you can contact the Board’s Advocate for Injured Workers at (800) 580-6665. They can provide guidance and support, making the process less daunting and ensuring you get the help you need.
What should I do if my request for medical treatment is denied?
If your request for medical treatment is denied, you should include the denial letter with your RFA-1W form. This documentation is essential for the Board to assess your situation effectively and determine appropriate next steps.
Can the RFA-1W form be used to report new information related to my claim?
Absolutely. The RFA-1W form allows you to report any new information the Board might need regarding your claim. Use the space provided on the form to elaborate on this information, and attach any relevant documents that could support your case.
Common mistakes
When filling out the RFA-1W form, mistakes can easily occur, leading to delays or complications in the processing of claims. Awareness of these common missteps can save time and ensure that requests for assistance are addressed efficiently. Here are nine significant mistakes individuals often make.
One common error involves failing to include all necessary medical documentation. For instance, if a person claims that their medical condition has changed, they must attach the relevant medical forms. Omitting these documents can result in a rejection of the request or additional delays as the Workers' Compensation Board seeks the necessary information.
Another frequent oversight is neglecting to address denial letters. If an individual’s request for medical treatment has been denied, it is critical to attach the denial letter to the form. The Board needs this information to review the case properly. Without it, they may not even consider the new information presented in the form.
Inaccurate information about employment status can be particularly problematic. Some individuals forget to specify concurrent employment or fail to attach the necessary pay statements when claiming their payments have been stopped or reduced. Providing misleading or incomplete information here could not only delay the process but also potentially question the legitimacy of the claim.
Many people also overlook the importance of including the appropriate contact information. Failing to fill out sections like the injured worker's mailing address or phone number can hinder communication with the Board. Accurate details facilitate timely updates and help prevent misunderstandings.
Additionally, not checking relevant boxes on the form can create confusion. Each checkbox corresponds to specific issues, and it’s vital to check all that apply. Ignoring certain boxes may lead to a lack of acknowledgment of all matters requiring attention and necessitate additional submission later.
A significant yet easily avoidable mistake involves not signing or dating the form. A form that is not signed or dated lacks validity and will likely be returned or considered incomplete. This simple act is essential for ensuring the request is processed without further complications.
Moreover, participants sometimes misunderstand the documentation needed for their state and fail to reference it correctly. When additional documents have been submitted before, it is important to identify them accurately by providing the form number or title and date. Failure to do so can lead to confusion regarding what information has already been reviewed.
It is also crucial to remember that any medical documentation submitted must show a direct link to the claimed injuries or conditions. Attaching unrelated or irrelevant medical records could detract from the claim’s strength and lead to unnecessary delays.
Finally, one must not forget the necessity of submitting the form and attachments via the proper channels, whether that’s mailing, faxing, or emailing. Failing to follow the outlined submission methods could lead to complications in tracking and processing the request. Adhering to the specific guidelines ensures that everything is delivered as intended, streamlining the process.
By being mindful of these common mistakes when completing the RFA-1W form, individuals can significantly enhance their chances of having their requests for assistance addressed promptly and effectively.
Documents used along the form
The RFA-1W form is an important document used by injured workers to communicate specific needs or issues related to their claims. When filing this form, various additional documents may also be required to support the request or to provide essential information. Below is a list of commonly used documents that accompany the RFA-1W form.
- Form C-3: Claim Petition - This form is used to officially file a claim for a work-related injury. It provides the necessary details about the injury and the circumstances surrounding it, initiating the claims process with the Workers' Compensation Board.
- Form C-4.3: Doctor’s Report of MMI/Permanent Impairment - Required when a worker's disability is permanent. This form confirms the medical condition and indicates the extent of impairment determined by a healthcare professional.
- Form C-257: Reimbursement Request - This document is used to request reimbursement for medical expenses and other costs related to the injury. Attach receipts and relevant documentation to support the request.
- Denial Letter - If a request for medical treatment or reimbursement has been denied, this letter outlines the reasons for the denial. It is important to include this letter when communicating any ongoing issues with claims that need to be re-evaluated.
- Form HP-1: Administrative Award - This form allows healthcare providers to file for an administrative award if there is no response to a bill after 45 days. It pertains to medical treatment costs that have not been settled with the insurer.
In summary, including these documents alongside the RFA-1W form can significantly bolster the injured worker's request. Having all necessary forms and supporting documentation will help ensure a smoother process when dealing with the Workers' Compensation Board. Always verify that the correct forms are attached to facilitate timely responses and resolutions to ongoing issues.
Similar forms
- Form C-3: This document serves as the initial claim form for reporting a work-related injury. Unlike the RFA-1W, which addresses specific issues arising during an ongoing claim, Form C-3 is used primarily to initiate the claims process.
- Form C-4: Used to provide medical information about an injured worker’s condition, Form C-4 specifically records the medical treatment that the worker has received. The RFA-1W may refer to this form when changes in medical status affect ongoing payments or treatments.
- Form C-257: This form is utilized for the documentation of medical expenses incurred by the injured worker. The RFA-1W features a request for receipts and Form C-257 to validate reimbursement claims for medical costs.
- Form C-8.1A: This form is employed by insurers to deny medical treatment based on specific guidelines or conflicting medical evidence. In contrast, the RFA-1W allows the injured worker to report that their requested treatments have been denied.
- Form C-4.3: This is the Doctor's Report of Maximum Medical Improvement (MMI) and Permanent Impairment. The RFA-1W asks for this documentation when an injured worker's condition has stabilized and is considered permanent.
- Form HP-1: This form is for requesting an administrative award from the Workers' Compensation Board when payments have not been made within a specified timeframe. The RFA-1W is used to communicate similar delays or gaps in compensation payments.
- Form C-67: The Supplemental Injury Report provides additional evidence regarding the work-related injury after the initial claim. The RFA-1W can reference new developments or information that can arise during the claims process.
- Form C-84: This document is utilized to request wage replacement benefits after a period of disability. The RFA-1W encompasses requests related to compensation and can parallel requests made in Form C-84 during or after a period of leave.
Dos and Don'ts
When filling out the RFA-1W form, it is crucial to ensure that the information is accurate and complete. Below are four key do's and don'ts to keep in mind:
- Do: Attach all required documents, such as medical reports or denial letters, to support your claims.
- Do: Clearly mark any changes in your medical condition or employment status as instructed on the form.
- Don't: Leave any sections blank unless specifically instructed, as this may delay processing your request.
- Don't: Provide false information or omit important details, as this can result in serious legal consequences.
Misconceptions
Misconceptions about the RFA-1W form can lead to confusion for injured workers seeking assistance. The following list addresses seven common misunderstandings:
- The RFA-1W form is a claim form. Many individuals mistakenly believe that the RFA-1W can be used to file an initial claim for a work-related injury. In reality, the RFA-1W is intended for requesting assistance after a claim has already been filed.
- You cannot attach documents to the RFA-1W form. Some people think that the form must be submitted without additional documents. However, it is critical to attach relevant medical reports and communication regarding any issues with your claim.
- All information needs to be submitted again with each RFA-1W form. It is a common belief that if information was previously submitted, it must be reattached. Instead, you can refer to previously submitted documentation, specifying the form number, title, and submission date.
- The Board will automatically resolve issues related to your claim. A misconception exists that filing the RFA-1W guarantees action from the Board. While the Board will review your request, you must actively follow up on any ongoing issues.
- There is no deadline for submitting the RFA-1W form. Some individuals might think that as long as they eventually submit the form, timing does not matter. However, prompt submission is crucial for addressing ongoing issues or delays.
- Medical documentation is unnecessary for all requests. Many believe that they can submit the RFA-1W without supporting medical evidence. In fact, attaching relevant medical documentation is often essential to support claims related to disabilities and treatment.
- You must have legal representation to file the RFA-1W. Some individuals think it is mandatory to have an attorney to submit the form. However, injured workers can file the RFA-1W independently, although legal assistance may be beneficial in complicated cases.
Understanding these misconceptions can help navigate the filing process more effectively and ensure proper management of claims with the Workers' Compensation Board.
Key takeaways
Filling out the RFA-1W form can be a straightforward process if you keep a few key points in mind. Understanding these components can help ensure that your requests are addressed efficiently by the Workers' Compensation Board.
- Understand the Purpose: The RFA-1W form is specifically designed for injured workers to request actions regarding their claims or to raise issues affecting their claims.
- Complete Required Information: Ensure all identifying information is filled out correctly, including date of injury, your personal information, and employer details.
- Attach Necessary Documentation: Attach all required documents pertinent to your requests, such as medical reports, denial letters, or pay stubs, to support your case.
- Check All Relevant Boxes: Mark all applicable items that reflect your situation accurately. This aids the Board in processing your request without unnecessary delays.
- Submit to the Correct Channels: It is crucial that you send the form and attachments to the appropriate address, whether via mail, fax, or email, as specified.
- Follow Up: After submission, monitor your claim status using the Board's online system or contact the Board directly for updates on your request.
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