Go to Form Instructions for Completing the Physician’s Report Please read all pages This form is “fillable.” That means you can type the information onto the form from your computer and print the form. You will not be able to save the form onto your computer’s hard drive. When you open the form, click in the appropriate check box (field) and use the tab key to navigate to the next field. To fill in a check box, click inside the box with your mouse. Do not use the Enter key; pressing the Enter key will only page down. Each field has been limited. This means that you cannot continue to type information into a field if it doesn’t fit into the space provided. Use numbers only to fill in the fields for Social Security # and phone and fax numbers . Do not use dashes or parentheses; when you tab out of the field, it will fill in automatically. To clear or delete all the information you have typed onto the form, click on the red “Clear Entire Form” button. To change the information in one field, use the backspace or delete key. 1 American LegalNet, Inc. www.FormsWorkflow.com “Check Box” Click in Box “Clear Entire Form” button Clears all information at once 2 American LegalNet, Inc. www.FormsWorkflow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION Back to Instructions Clear Entire Form PHYSICIAN’S REPORT OF WORKER’S COMPENSATION INJURY 1. 2. 3. A COPY OF THIS REPORT MUST BE SENT TO THE INJURED WORKER AND THE INSURER. REPORT TYPE Initial Progress Closing CASE INFORMATION Date of Injury Injured Worker’s Name Social Security # Date of Birth Exam Date Workers’ Comp # Insurer Claim # Insurer Name Insurer Phone/Fax Employer Name Employer Phone/Fax INITIAL VISIT (only) Injured worker’s description of accident/injury Are your objective findings consistent with history and/or work related mechanism of injury/illness ? 4. CURRENT WORK STATUS 5. Yes No WORK RELATED MEDICAL DIAGNOSIS (ES) Is Working 6. PLAN OF CARE a. TREATMENT PLAN Diagnostic tools/tests Procedures Therapy Medications Supplies Other b. WORK STATUS Able to return to full duty on Able to return to modified duty from c. LIMITATIONS/RESTRICTIONS Lifting (maximum weight in pounds) Repetitive lifting Carrying Pushing / Pulling Pinching / Gripping Reaching over head Reaching away from body Repetitive Motion Restrictions Not Working Unable to work from Able to return to part time work on to No Restrictions lbs. lbs. lbs. lbs. Temporary Restrictions Walking Standing Sitting Crawling Kneeling Squatting Climbing to for hrs per day Permanent Restrictions hours per day hours per day hours per day hours per day hours per day hours per day hours per day Other 7. FOLLOW UP CARE AND REFERRALS a. Return Appointment Date b. Referral for Treatment (specify ) Impairment Rating Referral Appointment to be made by Injured Worker Referred Provider’s Name and Address Discharged for non-compliance Discharged from care (explain) c. 8. Evaluation (specify) Other (specify) Referring physician’s office Phone Number MAXIMUM MEDICAL IMPROVEMENT (MMI) Injured Worker has reached MMI Maintenance care after MMI required? Date No Yes If yes, specify care Injured Worker is not at MMI, but is anticipated to be at MMI in/on MMI date unknown at this time because 9. PERMANENT MEDICAL IMPAIRMENT No permanent impairment Anticipate permanent impairment 10. Permanent Impairment (attach required worksheets and narrative) Needs referral to Level II physician for impairment rating (see 7 b above) PHYSICIAN’S SIGNATURE Date of Report Print Name License number Address Telephone Number WC164 05/06 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS / DEFINITIONS The use of this form is required by the Workers’ Compensation Rules Of Procedure Rule 16-7(E)(1), 7 CCR 1101-3 to report all information specific to this workers’ compensation injury. Complete all applicable fields and attach your narrative report that further describes and supports your findings. Your narrative report does not replace this form. 1. Report Type: Check “Initial” if this is the first visit related to this described injury. Check “Progress” when a change in condition, diagnosis, or treatment occurs. Check “Closing” if: injured worker is at MMI, requires an impairment rating, or is discharged from care. 2. Case Information: ♦ Date of Injury: Date of this injury. ♦ Injured Worker’s Name: Name of the injured worker. ♦ Social Security #: The injured worker’s social security number. ♦ Date of Birth: The injured worker’s date of birth. ♦ Exam Date: Date of office visit if applicable. ♦ Workers’ Comp #: The Workers’ Compensation number assigned by the Division to the claim, if known. ♦ Insurer Claim #: The claim number assigned by the insurance carrier or self-insured employer, if known. ♦ Insurer Name: The name of the insurance carrier or self-insured employer associated with the claim. ♦ Insurer Phone/Fax: The phone and fax numbers of the insurance carrier or self-insured employer associated with the claim. ♦ Employer Name: The name of the employer associated with the claim. ♦ Employer Phone/Fax: The phone and fax numbers of the employer. 3. Initial Visit: ♦ Relate in injured worker’s words description of accident/injury. ♦ Check the applicable box regarding physician’s objective findings. 4. Current Work Status: Current work status as related by injured worker. 5. Work Related Medical Diagnosis(es): State the injured worker’s work related medical diagnosis(es). 6. Plan of Care: a. Treatment Plan: Complete all applicable portions regarding treatment. Indicate frequency and duration. ♦ Diagnostic tools/tests: EMG, MRI, CT-scan, etc. ♦ Procedures: Any medical procedure including surgical procedures, castings, etc. ♦ Therapy: Physical therapy, occupational therapy, home exercise, etc., include plan specifications. ♦ Medications: Antibiotics, analgesics, anti-inflammatory drugs, etc. ♦ Supplies: Durable medical equipments, splints, braces, etc. ♦ Other: Any treatment not covered above. b. Work Status: Check the applicable work status box(es). List date(s) and hours as appropriate. c. Limitations/Restrictions: Check the applicable box(es) regarding any medical or physical limitations or restrictions including temporary or permanent restrictions. 7. Follow Up Care And Referrals: a. Provide the date of the next scheduled appointment. b. If a referral was made to another provider, supply that provider’s name, address, and phone number. Designate who is to make the referral appointment. c. Complete and explain applicable discharge information. 8. Maximum Medical Improvement (MMI): Check the applicable box(es). List additional information as appropriate. MMI means a point in time when any impairment resulting from the injury has become stable and when no further treatment is reasonably expected to improve the condition. Maintenance care is medical care subsequent to a finding of MMI which is designed to prevent further deterioration from the injury. In some cases MMI may be unknown because the injured worker has not returned for care. 9. Permanent Medical Impairment: Check the applicable box(es). If the injury will cause a permanent impairment, an impairment rating performed by a Level II accredited physician is required. If an impairment rating is given, attach the worksheets required by the Division and a report describing the extent of the injured worker’s impairment rating. 10. Physician Information: List the name, license number, address, and telephone number of the physician responsible for the report. The physician responsible for the report must sign and date the report. WC164 05/06 American LegalNet, Inc. www.FormsWorkflow.com