STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 INSTRUCTION SHEET FOR FORM WC-2 PHYSICIAN'S REPORT Instructions Please completely fill out the WC-2 PHYSICIAN'S REPORT FORM. The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. Please remember to sign and date the form before submitting it. Delivery Information Delivery by U.S. Mail, In-Person, or via Fax Oahu Princess Keelikolani Building 830 Punchbowl Street, Room 209 Honolulu, Hawaii 96813 Mailing Address: P.O. Box 3769 Honolulu, Hawaii 96812-3769 Phone: (808) 586-9161 Fax: (808) 586-9219 Hawaii 75 Aupuni Street, Room 108 Hilo, Hawaii 96720 Phone: (808) 974-6464 Fax: (808) 974-6460 West Hawaii Ashikawa Building 81-990 Halekii Street, Room 2087 Kealakekua, Hawaii 96750 If Mailing, Please Mail to This Address: P.O. Box 49, Kealakelua, Hawaii 96750 Phone: (808) 322-4808 Fax: (808) 322-4813 Kauai 3060 Eiwa Street, Room 202 Lihue, Hawaii 96766 Phone: (808) 274-3351 Fax: (808) 274-3355 Maui 2264 Aupuni Street #2 Wailuku, Hawaii 96793 Phone: (808) 984-2072 Fax: (808) 984-2071 Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 9/05) STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 FORM WC-2 PHYSICIAN'S REPORT Note: PLEASE DO NOT WRITE IN SHADED BLOCKS 1 First 2 First & Final 3 Final 4 Interim 5 Consulting 6 Rating Case Number Date this report received Mo. Employer Name and Address Carrier's Name and Address 1. 2. Patient's Name and Address Your Name, Address and Telephone No. 3. 4. Are you the attending physician? Has the patient been burned? Is there a possibility of other disfigurement? Do you think physical rehabilitation will be necessary? Do you think medical rehabilitation will be necessary? / Day Yes / Yr. No Patient's Social Security Number Date of Injury/Illness Mo. Physician's ID If patient expired, give date Mo. 5. Date of First Treatment Mo. / Day / Yr. / Day / Yr. / Day / Yr. State in patient's own words where and how the accident occurred: Give accurate description and extent of injury: specify all parts of the body involved and state objective findings. Is accident mentioned above the only cause of patient's condition? Yes No, state contributing causes. Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 10/05) FORM WC-2 PHYSICIAN'S REPORT Page 2 of 2 Who engaged your services? Is further treatment required? Were X-Rays taken? No No Yes, period of time required? Yes, by whom? Date(s) X-Ray Diagnosis: Was patient treated by anyone else? No Yes, by whom? Date(s) Was patient hospitalized? No Yes, date of admission: Date of Discharge: Name and Address of Hospital Describe subsequent treatment to be provided by you Did accident result in disability for work? Patient was will be able to resume Yes No, date disability began: regular work on: Patient discharged as cured on None light work Patient stopped treatment without orders on Describe any permanent defect or disfigurement (include scars, discolorations, deformities, etc.) Final Diagnosis: Physician Signature Date Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 10/05)