KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 2 MEDICAL MANAGEMENT CLOSURE REPORT K-WC-R 87-7 (9-13) Date of closure: __________________________________ Date of accident: ___________________________________ Vendor: _______________________________________________________________ Vendor number: _____________ Claimant: ________________________________________________ Social Security number: _____________________ Street: ___________________________________________________________________________________________ City: __________________________________________________________ State: _______ ZIP: _________________ Total cost for medical management services: $ _______________ Reason for Case Closure: 1. Claimant has returned to work. Job title: __________________________________________________________________________________________ ( ) Employer: _____________________________________________________ Phone: _____________________________ Street: ___________________________________________________________________________________________ City: __________________________________________________________ State: _______ ZIP: _________________ Date returned to work (mm/dd/yyyy): ___________________ Current average weekly wage (AWW): $ _______________ AWW at date of accident: $ __________________ Complete below if job modified or accomodations made. Modification/change made by employer to accommodate the physical limitation imposed by the injury/occupational disease: Documentation of claimant's abilities to perform selected vocational objective: I agree to return to work for employer with changes stated in this report. Claimant's signature: ___________________________________________________ Date: _______________________ It is my professional opinion that the position described in this plan is within the medical restrictions of this claimant. Medical manager's signature (REQUIRED): _________________________________ Date: _______________________ DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000, ext. 2152 American LegalNet, Inc. www.FormsWorkFlow.com KANSAS DEPARTMENT OF LABOR K-WC-R 87-7 (9-13) Medical Management Closure Report Reason for Case Closure (cont'd) 2. Claimant released to return to same job, same employer (without restriction); did not return to work. 3. Claimant released to return to same job, same employer (with restrictions); did not return to work. 4. Insurance company requested closure. Explain below: Page 2 of 2 5. Referred for vocational assessment. 6. Other (explain): Medical manager's signature (REQUIRED): _______________________________________ Date: __________________ Copy of closure report is required to be sent to claimant and attorney, if there is one. cc: DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000, ext. 2152 American LegalNet, Inc. www.FormsWorkFlow.com