October 2016 Edition Filed: FORM 107 Medical Report ­ Injury/Hearing Loss/Psychological Condition KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Medical Report of DR. A. 1. 2. 3. 4. 5. 6. 7. PLAINTIFF/EMPLOYEE INFORMATION Plaintiff/Employee's name: Last four digits of Social Security Number/Green Card: Date of birth: Plaintiff/Employee's job title and employer: Date of examination(s): By whom was the examination requested: Prior examination(s) by this physician (if any) and date(s): B. PLAINTIFF/EMPLOYEE HISTORY Plaintiff/Employee related history of complaints or alleged injury/hearing loss/psychological condition as follows: C. TREATMENT - Prior and Current Based upon a review of records and/or history related by plaintiff/employee, treatment provided for this injury has been as follows: (Include any periods of hospitalization.) American LegalNet, Inc. www.FormsWorkFlow.com D. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings to support complaints and/or diagnosis: E. DIAGNOSTIC TESTING/Injury Include any testing reviewed and relied upon for medical conclusions. This will include X-rays, CT scans, MRIs, Myelograms, EMG/NCVs or Other (please specify). Personally Test Date Reviewed Summary of Results F. DIAGNOSTIC TESTING/Hearing Loss Include any testing reviewed and relied upon for medical conclusions. This will include Comprehensive Audiometry, Immitance Audiometry, Otoacoustic Emissions, Communication Needs Assessments, or Other (please specify). Test Date Summary of Results American LegalNet, Inc. www.FormsWorkFlow.com G. DIAGNOSTIC TESTING/Psychological Include any testing reviewed and relied upon for medical conclusions. This will include Neuropsychological (e.g., Luria-Nebraska, Halstead-Reitan), Academic/Achievement (e.g., WRAT-R), Intellectual Capacity, Personality ( e.g., MMPI, Millon, etc.), Brain Imaging (MRI, CT, SPECT), or Other (please specify) Test Date Summary of Results H. SURGICAL PROCEDURE(S) Specify type and date of any surgical procedure. Include operative note if surgery performed by this physician. I. DIAGNOSIS J. CAUSATION 1. Do you believe the work event as described to you is the cause of the impairment found? 2. Is any part of the impairment due to a cause other than the work event described above? 3. If yes, what is that cause and the impairment attributable to that cause? Yes Yes No No 4. If applicable, do audiograms and other testing establish a pattern of hearing loss compatible with that caused by hazardous noise exposure in the workplace? Yes No 5. If applicable, within reasonable medical probability, is plaintiff/employee's hearing loss related to repetitive exposure to hazardous noise over an extended period of employment? Yes No 6. If applicable, within reasonable medical/psychological probability, is plaintiff/employee's psychological condition the direct result of the physical work-related injury? Yes No K. IMPAIRMENT 1. Using the edition of the AMA Guides to the Evaluation of Permanent Impairment, the Plaintiff/Employee's permanent whole person impairment is %. 2. Chapters, Tables and Pages utilized to arrive at impairment rating for injuries: American LegalNet, Inc. www.FormsWorkFlow.com Body Part or System a. b. c. Chapter Number Table Number Page Number % Impairment of the Whole Person 3. Plaintiff/employee had an active impairment prior to this injury. A. If yes, specify condition producing active impairment. Yes No B. If yes, specify percentage of impairment due to the prior active condition. 4. Date on which maximum medical improvement was reached: 20 . L. RESTRICTIONS 1. The plaintiff/employee described the physical requirements of the type of work performed at the time of injury as follows: 2. Does the plaintiff/employee retain the physical capacity to return to the type of work performed at the time of injury? Yes No If not, why? 3. Which restrictions, if any, should be placed upon plaintiff/employee's work activities as the result of the injury? M. CERTIFICATION and QUALIFICATIONS of PHYSICIAN I hereby certify that the above information is correct and that all opinions were formulated within the realm of reasonable medical probability. A copy of my curriculum vitae is attached if I have not obtained a Department of Workers' Claims Physician Index Number. Date Full name of Physician Department of Workers' Claims Physician Index Number American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completion of Form 107 The medical report forms of the Department of Workers' Claims are designed to provide relevant medical information to administrative law judges to assist in determining the occupational implications of a work-related injury or an occupational disease. Therefore, it is important that each section of the forms be carefully and fully completed. 1. 2. All information must be typed or neatly printed. The Department of Workers' Claims maintains a Physician Index with curricula vitae of physicians. Physicians may be included in the index by tendering a copy of a current curriculum vitae with a request for inclusion to: Physicians Index Clerk, Department of Workers' Claims, 657 Chamberlin Avenue, Frankfort, Kentucky 40601. The AMA Guides to the Evaluation of Permanent Impairment is mandated by statute. Prior to the completion of the Form, the Physician should become familiar with the edition currently directed by statute and regulation to be used. Reference should be made to chapters, page numbers, and tables for all physical injuries. For psychiatric conditions, the class of impairment should be stated, with reference to impairment ratings provided in prior editions. Objective medical findings to support a medical diagnosis means information gained through direct observation and testing of the plaintiff/employee, applying objective or standardized methods. KRS 342.0011(33). Medical opinions must be founded on reasonable medical probability, not on mere possibility or speculation. Young v. Davidson, Ky., 463 S.W.2d 924 (1971). Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. 3. 4. 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com