Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Complete Boxes 1 - 9, which contain employee information. Ensure that all relevant details about the injured worker are accurately filled out, particularly questions 8 and 9.
3. Fill in Box 10 with the date of the injury. For traumatic injuries, this is the actual date of the accident. For other types of injuries, use the guidelines provided in the form.
4. In Box 11, enter the CMS date of incident as defined by the Centers for Medicare & Medicaid Services. Follow the instructions carefully to select the correct date.
5. Provide a detailed Injury Description in Box 12, explaining how the injury occurred and specifying the injured body parts.
6. In Box 13, list any surgeries that resulted from the injury, including dates and the names of the doctors who performed them.
7. Fill out Box 14 with the Diagnosis or Nature of Illness or Injury ICD-9-CM Codes. Ensure to include at least one code and attach a Health Insurance Claim Form if necessary.
8. In Box 15, indicate whether you have received worker’s compensation benefits for this injury. Specify the name of the insurance carrier and the date of your last payment.
9. Sign and date the form in Boxes 16 and 17 to finalize your application. Ensure that your signature is complete and accurately reflects your information.
10. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

Ensure your application is completed accurately by following these steps and submit your Wkc 7 Hearing Application Fillable Version Form online today.