C 72 1 form 2025

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The document is a form from the New York Workers' Compensation Board used to calculate and report percentage hearing loss due to occupational exposure. It outlines the procedure for measuring hearing levels in both ears at specific frequencies, adjusting for baseline hearing loss, and determining binaural hearing loss percentages. The form also includes certification requirements for audiometric testing and a notice regarding HIPAA compliance related to medical reporting.

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Click ‘Get Form’ to open the c 72 1 form in the editor.
Begin by entering the claimant's name and WCB Case Number at the top of the form. This information is essential for identifying the case.
In the 'Hearing Levels' section, input the results from audiometric tests for both right and left ears at specified frequencies (500 Hz, 1,000 Hz, etc.). Ensure accuracy as these values are critical for calculating hearing loss.
If multiple tests were conducted, record the lowest hearing levels at each frequency in section D. This will help in determining the average hearing loss.
Calculate the Adjusted Hearing Loss by subtracting 25 db from your average hearing levels and then multiplying by 1.5 to find the percentage of binaural hearing loss.
Complete the certification section by signing and dating it, ensuring that all test conditions meet required standards.

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What is the fax number for the New York State Department of Corporations?

You may fax a document submitted for filing to the Division of Corporations at (518) 474-1418. Written requests for copies of documents, certificates of status and name availability may be faxed to (518) 473-1654.

What is the fax number for the New York State Workers Compensation Board?

Email to the Boards centralized email address, wcbclaimsfiling@wcb.ny.gov; Mail to the Boards centralized mailing address, P.O. Box 5205, Binghamton, NY 13902-5205; or. Fax to the Boards centralized fax number, (877) 533-0337.

What is the fax number for NYS DOL?

Fax: 518-457-9378. Mail: New York State Department of Labor, P.O. Box 15130, Albany, NY 12212-5130.

What is the fax number for NYS disability?

NYSIF Disability Benefits You may also fax your NYSIF DB-450 to 518-437-5201. Be sure to keep a copy for your records.

What is the fax number for New York State and Local Retirement System?

Fax the application to 518-474-3091 or 518-408-3587. The transmission date will serve as the filing date, but you will still need to mail the original documents for processing.

What is a C4 form for workers comp?

In order to receive these benefits, youll need to fill out a C4 form. This form is used to report your injury to your employer and to the workers compensation insurance carrier.

C 72 1 form 2025

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What is the fax number for the New York State Department of Corporations?

What is the fax number for the New York State Workers Compensation Board?

What is the fax number for NYS DOL?

What is the fax number for NYS disability?

What is the fax number for New York State and Local Retirement System?

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What is a C4 form for workers comp?

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C 72 1 form 2025

Here's how it works

How to use or fill out c 72 1 form with our platform

See more c 72 1 form versions

Complete this form in 5 minutes or less

Got questions?

What is the fax number for the New York State Department of Corporations?

What is the fax number for the New York State Workers Compensation Board?

What is the fax number for NYS DOL?

What is the fax number for NYS disability?

What is the fax number for New York State and Local Retirement System?

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What is a C4 form for workers comp?

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