State of California Additional pages attached PRIMARY TREATING PHYSICIAN'S PROGRESS REPORT (PR-2) Check the boxes which indicate why you are submitting a report at this time. If the patient is "Permanent and Stationary" (i.e., has reached maximum medical improvement), do not use this form. You may use DWC Forms PR-3 or PR-4. Periodic Report (Required 45 days after last report) Change in work status Change in patient's condition Other Change in treatment plan Release From Care Need for referral or consultation Need for surgery or hospitalization Response to request for information Request for authorization Patient Patient last name: Patient Street Address/PO Box Occupation Patient first name: Patient City Phone Number State Date of Birth Date of Injury Zip Code MI Sex Claims Administrator Claims Administrator Name Claims Administrator Street Address/ Phone Number Fax Number Claim number Claims Administrator City Employer Name State Zip Code Phone Number The information below must be provided. You may use this form or you may substitute or append a narrative report. Subjective Complaints: Objective findings: (Include significant physical examination, laboratory, imaging, or other diagnostic findings.) Diagnoses: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. DWC Form PR-2 (Rev. 10/2015) Sheet 1 of 2 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 American LegalNet, Inc. www.FormsWorkFlow.com 11. 12. ICD-10 ICD-10 Treatment Plan: Include treatment rendered to date. List methods, frequency and duration of planned treatment(s). Specify consultation/ referral, surgery, and hospitalization. Identify each physician and non-physician provider. Specify type, frequency and duration of physical medicine services (e.g., physical therapy, manipulation, acupuncture). Use of CPT codes is encouraged. Have there been any changes in treatment plan? If so, why? Work Status: This patient has been instructed to: Remain off-work until Return to modified work on standing, sitting, bending, use of hands, etc.): with the following limitations or restrictions. (List all specific restrictions re: Return to full duty on with no limitations or restrictions. Date of Exam Primary Treating Physician: (original signature, do not stamp) I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code section 139.3. Physician signature Executed at: Physician Name Physician address: Cal. License Number: Date (mm/dd/yyyy): Specialty: Phone Number PRIVACY NOTICE: A statement of current data collection and use policies and certain privacy rights of injured workers may be found at the following website: http://www.dir.ca.gov/od_pub/privacy.html. DWC Form PR-2 (Rev. 10/2015) Sheet 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com