October 2016 Edition Filed: FORM 108 - OD Medical Report � Occupational Disease KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Medical Report of DR. A. 1. 2. 3. 4. 5. 6. 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): Purpose of examination: Treatment Evaluation requested by University Evaluation Prior evaluation(s) by this physician (if any) and date(s): 7. B. PLAINTIFF/EMPLOYEE HISTORY Plaintiff/employee related history of complaints allegedly due to an occupational disease as follows: Note: If the occupational disease is lung or heart-related, include plaintiff/employee's smoking history. C. EMPLOYMENT HISTORY Employment History (Form 104) dated , 20 was reviewed with plaintiff/employee for accuracy and pertinent employment history is listed. If no 104 was reviewed, state the history received from the plaintiff/employee. American LegalNet, Inc. www.FormsWorkFlow.com October 2016 Edition D. TREATMENT - Prior and Current Based upon a review of records and/or history related by plaintiff/employee, treatment (including any periods of hospitalization) provided for the above complaints has been as follows: (list medical records reviewed) E. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings related to the occupational disease. If the occupational disease is lung or heart-related, include all findings pertinent to the respiratory and cardiovascular systems. F. DIAGNOSTIC TESTING Include any testing reviewed and relied upon for medical conclusions. This will include X-rays, CT scans, MRI, Chest x-ray � Use ILO Classification and attach ILO Form if alleging a pneumoconiosis, Other x-rays reviewed of plaintiff/employee and dates (use ILO Classification and attach ILO Form if alleging pneumoconiosis), Pulmonary function testing pre-bronchodilator, Pulmonary function testing post-bronchodilator, if indicated, or Other (please specify): Test Date Personally Reviewed Summary of Results American LegalNet, Inc. www.FormsWorkFlow.com October 2016 Edition F. Test Date DIAGNOSTIC TESTING, Con't Personally Reviewed Summary of Results G. DIAGNOSIS H. IMPAIRMENT 1. Using the Edition of the AMA Guides to the Evaluation of Permanent Impairment, the plaintiff/employee's permanent whole body functional impairment is %. If the impairment is due to loss of pulmonary function, give class and percentage. 2. Chapter, Tables, and Pages utilized to arrive at impairment ratings: Body Part or System a. b. c. Chapter Number Table Number Page Number % Impairment of the Whole Person American LegalNet, Inc. www.FormsWorkFlow.com October 2016 Edition 3. Plaintiff/employee had a prior active impairment. a. b. Yes No For yes, specify condition producing active impairment: For yes, specify percentage of impairment due to the prior active condition. I. 1. 2. CAUSATION Within reasonable medical probability, is plaintiff/employee's disease or condition causally related to his/her work environment? Yes No Within reasonable medical probability, is any pulmonary impairment caused in part by factors in plaintiff/employee's work environment (e.g., coal dust, chemicals)? Yes No If yes, explain: 3. Identify the relevant factors in the work environment and explain the causal relationship between the factors in the work environment and the above diagnosis. J. 1. RESTRICTIONS 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 no, explain: 3. Which restrictions, if any, should be placed upon plaintiff/employee's work activities as the result of the injury? American LegalNet, Inc. www.FormsWorkFlow.com October 2016 Edition K. RECOMMENDATIONS FOR TREATMENT L. 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 or 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 October 2016 Edition Instructions for Completion of Form 108-OD 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 chapter, 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. Height of a patient should be measured in centimeters and without shoes. If the patient's height is an odd number of centimeters, the next highest even height in centimeters shall be used. Objective medical findings to support a medical diagnosis means information gained through direct observation and testing of the patients, 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. 7. American Legal