COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. M-1 : REASON FOR REPORT CIRCLE ONE INITIAL PROGRESS FINAL -againstE M P L O Y E E PRACTITIONER'S REPORT : STATE OF MAINE WORKERS' COMPENSATION : BOARD Plaintiff(s) Office of Medical/Rehabilitation : Services EMPLOYER NAME: EMPLOYEE LAST NAME: EMPLOYER MAILING ADDRESS & PHONE #: TYPE Index No. OF PRACTITIONER CIRCLE ONE Calendar No. MD DO DC JUDICIAL SUBPOENA LIST OTHER _____________________ ADDRESS - NUMBER AND STREET: : INSURER NAME: . ........ : FIRST NAME: Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . CITY:. . . . . . . . . . . . . . . . . . . STATE: ... INSURER MAILING ADDRESS: DATE OF INJURY: ZIP: M.I.: HOME PHONE: SSN: THE PEOPLE OF THE STATE OF NEW YORK PATIENT'S COMPLAINTS: TO ICD-9 CODE: IN GREETINGS: PROBLEM IS MY OPINION, THIS WORK RELATED YES HAVE DIAGNOSTIC TESTS BEEN PERFORMED? P R A C T I T I O N NOT WORK RELATED IS NOT YET IDENTIFIED AS TO CAUSE NO RESULTS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court IS TREATMENT TO CONTINUE? YES NO DATE OF THIS EXAMINATION : / / located at County of DATEroom / in PATIENT TO BE SEEN AGAIN: , on the day/ of ESTIMATED ,LENGTH OF TREATMENT? 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the TREATMENT PLAN: LIST ANY MEDICATION PRESCRIBED FOR THIS DIAGNOSIS/CONDITION THAT WOULD PREVENT YOUR PATIENT FROM DRIVING AND/OR WORKING SAFELY: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. IF UNABLE TO WORK, ADVISE ESTIMATED DATE OF RETURN : Witness, HonorableDUTY REGULAR WORK CAPACITY: Court in County, day of RESTRICTIONS / / P.I. RATING : / / , one of the Justices of the NO WORK CAPACITY MODIFIED DUTY , 20 DESCRIBE: YES/NO (Attorney must sign above and type name below) E R Attorney(s) for IS PERMANENT IMPAIRMENT EXPECTED? YES NO HAS MMI BEEN REACHED? YES Office and P.O. Address NO SIGNATURE OF PRACTITIONER TELEPHONE #: WCB M-1 (6/99) DISTRIBUTION: Telephone No.: Facsimile No.: PRINT NAME AND ADDRESS E-Mail Address: NARRATIVES ATTACHED? YES NO Mobile Tel. No.: PRACTITIONER (1) EMPLOYEE (2) EMPLOYER (3) INSURANCE COMPANY (4) American LegalNet, Inc. www.USCourtForms.com