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Medical Report Hearing Loss - Kentucky

Medical Report Hearing Loss - Kentucky 2025

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The document is a medical report form (FORM 108 - HL) used by the Kentucky Office of Workers Claims to evaluate hearing loss in plaintiffs. It includes sections for plaintiff information, history of complaints, employment history, treatment details, physical examination results, diagnostic testing, diagnosis, causation of hearing loss related to workplace exposure, impairment assessment, work restrictions due to hearing loss, and recommendations for treatment. The form emphasizes the importance of accurate completion for administrative law judges to assess occupational injuries or diseases.

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Click ‘Get Form’ to open the Medical Report Hearing Loss - Kentucky in the editor.
Begin by filling out the Plaintiff Information section. Enter the plaintiff’s name, address, Social Security number, date of birth, job title and employer, date of examination(s), and purpose of examination. Ensure all fields are completed accurately.
In the Plaintiff History section, provide a detailed account of complaints related to hearing loss. This is crucial for establishing context.
For Employment History, attach Form 104 and summarize any relevant exposure to environmental noise that may have contributed to hearing loss.
Complete the Treatment section by detailing prior and current treatments received for hearing loss, including any hospitalizations.
Fill in the Physical Examination results and Diagnostic Testing sections by checking applicable tests and summarizing their results.
Address Causation questions regarding whether hearing loss is related to workplace noise exposure. Provide clear answers based on medical findings.
Finally, complete the Impairment and Restrictions sections by assessing functional impairment percentages and any work activity restrictions due to hearing loss.

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How do I claim compensation for hearing loss?

Visit a qualified medical professional and get a proper diagnosis of deafness and/or tinnitus. To file a claim, you will need to produce an official medical report detailing the extent of your injury. Proving that your injury was caused because of the work environment is another essential requirement.

What is the average payout for hearing loss?

Your first step should be to see an audiologist or an ear, nose, and throat (ENT) specialist. They will conduct hearing tests to diagnose the extent and type of your hearing loss. This medical documentation is the most important piece of evidence for your workers compensation hearing loss claim.

Who is exempt from workers comp in Kentucky?

Under Kentucky workers comp laws, certain employees are exempt from coverage, including: Any person employed in agriculture. Members of a religious sect or organization that oppose insurance benefits. Domestic workers employed in a private home with less than two regularly employed workers.