Dept. of Labor & Industries PO Box 44239 : Calendar No. Olympia WA 98504-4239 : DOCTOR'S WORKSHEET FOR RATING DORSO-LUMBAR & LUMBO-SACRAL IMPAIRMENT JUDICIAL SUBPOENA : Dear Doctor: : This worksheet has been designed to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine. By performing this rating yourself, you can help prevent the need for Independent Medical Exams. You are also uniquely capable of accurately evaluating and explaining this evaluation to your own patient. : : .... This worksheet has been developed through the efforts of the medical, osteopathic and chiropractic communities. It has been reviewed by the business and labor communities, by the Department of Labor and Industries and by the legal community. It conforms to the rating requirement described in WAC 296-20-280. We hope this helps simplify the rating process for both you and the patient. Please contact me or your Claim Manager listed below with questions or comments. Sincerely, es being Hal Stockbridge, MD, MPH Associate Medical Director Department of Labor and Industries (360) 902-5022 laid aside, you and each of you attend before , Court t o'clock in noon, and at any recessed Dear Doctor: the this action on the part of the The purpose of this worksheet is to encourage attending physicians to perform impairment ratings on their own patients. Patients are often grateful to attending physicians who perform the rating, since it frequently eliminates the need for an Independent Medical Examination (IME). This worksheet is all you need to send to you liable to able as a contempt of court and will makethe claim manager if you are the attending physician (assuming that you have provided all the ximum required documentation -all damages sustained as a etc.). penalty of $50 and chart notes, history and physical, • For sending the worksheet, use billing code 1190M (See Medical Aid Rules and Fee Schedules for current reimbursement). Simply use this code on the usual billing form (HCFA 1500 - L&I version F245-127-000). Mail the HCFA 1500 of the , one of the Justicesto the usual address (PO Box 44269, Olympia, WA 98504-4269). • NOTE - To return completed copy: Tear back page off at the perforation. For your convenience fold page 4 so the address will show through a window envelope and mail. (Alternatively, use a regular envelope addressed to PO Box 44239, Olympia WA 98504-4239). (Attorney must sign above and type name below) • Keep this front sheet for your reference and copy page 3 for your records. • If you wish assistance with the impairment rating, you may contact the Office of the Medical Director at L&I, (360) 902-5022, Attorney(s) for 902-5028 or FAX (360) 902-4249. Sincerely, Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com F252-006-000 worksheet/dorso-lumbar & lumbo sacral 9-00 This WORKSHEET was developed jointly by representatives of the medical, osteopathic, and chiropractic communities, and has been reviewed by representatives of business, labor and the legal community. It is based on WAC 296-20-280. Page 1 COUNTY OF Department of Labor & Industries . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Doctor's.Worksheet . . . .Rating Dorso-Lumbar & Lumbo-Sacral Impairment . . . . . . . . . . . . . . . . . for . . . : Claimant's Claim # Index No. name : Step 1. (a) Has the worker's condition reached maximum medical improvement? Yes NoCalendardo not rate. Please provide treatment recommendations. If “No,” No. (b) If there is a pre-existing condition, was it permanently aggravated by the industrial injury? Yes No N/A If “Yes,” attach explanation. Step 2. Is there any permanent impairment? Yes : No Plaintiff(s) Step 3. Circle one box in each column A through D below. Give brief explanation below (REQUIRED). Your entries should reflect the patient's current JUDICIAL SUBPOENA -againstA Muscle Weakness AND: EITHER Atrophy or EMG abnormalities (See "notes".below.) . ...... .... B Reflex loss (In general only Asymmetric losses are significant.) : C Imaging and X-ray findings : EXAMPLES: Degenerative disk disease, fracture disrupting the spinal canal, bulging disc : (Only include findings which are consistent with clinical picture.) Defendant(s) : .......................................... Circle one Circle one none (1) none (1) Explain: Circle one none (1) THE PEOPLE OF THE STATE OF NEW YORK knee ankle TO yes yes Tear on perforated line (3) mild but GREETINGS: D Other Findings EXAMPLES: Dermatomal sensory loss, decreased range-of-motion, muscle guarding, +SLR (Only include findings which are consistent with the clinical picture.) NOT TO BE CONSIDERED: OSWESTRY OR OTHER PAIN SCALES Explain: Circle one none (1) mild intermittent (2) mild continuous or moderate intermittent (3) mild but significant that(4) business all moderate (5) significant (4) WE COMMAND YOU, and excuses being laid aside, you and each of you attend before moderate , the Honorable at the Court continuous or marked located at County of in room , on the day of , 20 , at o'clock intermittent noon, and at any recessed in the (5) or adjourned date, to testify and give evidence as a witness in this action on the part of the moderate (6) marked (7) marked (6) marked continuous (7) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to essentially Give muscle group the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a total loss of and specific low back result of your failure to comply. abnormalities: functions (8) Box number circled Step 4: Calculate Rating (If you want Witness, Honorable , one of the Justices of the in Column A: L&I to do the calculation, copy the numbers Box number circled Court in County, day of , 20 the 1st 4 boxes and go to Step 5.) into in Column B: Box number circled Notes: • Column A: Mild Weakness = 4/5 (Complete motion against gravity and less than full resistance); in Column C: Moderate = 3/5 (Barely complete motion against gravity); Box (Attorneyevidence of above and type name below)number circled must sign contractility). Marked = 2/5 - 0/5 (Complete motion with gravity eliminated to no in Column D: Total • Pain is considered in the rating, but must be reflected in findings described on this worksheet (for example, decreased range-of-motion). Average (total divided by 4) Enter the average rounded to nearest whole number (1.1=1, 1.5=2, etc.) This is the rating: Attorney(s) for I certify that I have examined the patient within the last 8 weeks and that the above report truly and correctly sets Office and P.O. Address forth my findings and opinion. Step 5: Doctor's address Certification Print Dr's name ZIP+4 Today's date Provider No. Doctor's signature Telephone No.: The Physician should photocopy this worksheet for their medical records. Facsimile No.: Doctors should refer to the Medical Examiner's Handbook for E-Mail Address: instructions on the use of this worksheet. Mobile communities Developed jointly by representatives of the medical, osteopathic and chiropracticTel. No.: with input from Labor and Business; based on WAC 296-20-280 F252-006-000 worksheet/dorso-lumbar & lumbo sacral 9-00 American LegalNet, Inc. www.USCourtForms.com Page 3 : Definitions and Instructions : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . The .“Fixed .and .Stable”. Concept .... ....... .... ....... .. Impairment is fixed and stable when it is reasonably certain that further medical treatment will not predictably alter the course of the illness or medical condition, i.e., there is no significant probability that the level of impairment OF be decreased THE PEOPLE OF THE STATE will NEW YORK by the treatment. Fixed does not mean healed or static; rather, it means the worker has reached a stable plateau from TO which further recovery is not expected, though the passage of time may produce some benefit. The accepted condition can be rated when it has reached a peak of possible recovery, given the worker's total medical condition. For example, the background of the worker's total medical condition GREETINGS: might include smoking, substance abuse or concurrent medical problems. It is not necessary to defer the rating until all on-going potentially complicating conditions have been resolved. COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE , the Honorable Court If the worker's condition is deteriorating atat the a rate that medical treatment is needed for such locatedtotal loss of function cannot be predicted, the worker's at County of the accepted condition and the condition is not stable, then his or her impairment at in room , on the day of , 20 , should NOT be rated (unless you have recessed o'clock in the noon, and at any received date, to testify and give evidence Claim Manager). action on situation you should make special instructions from the as a witness in this In this the part of the or adjourned treatment recommendations. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for For your mailing convenience, This form has been designed so you only need to tear the last page (pages 3 and 4) off, fold and insert into a standard window envelope. Please check to ensure the L&I address is showing through the window before sealing. Office and P.O. Address !985044239394! Department of Labor & Industries PO Box 44239 Olympia WA 98504-4239 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com F252-006-000 worksheet/dorso-lumbar & lumbo sacral 9-00 Page 4