Mississippi Workers Compensation Commission PRELIMINARY REPORT Q MEDICAL REPORT PROGRESS REPORT Q THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE MISSISSIPPI WORKERS COMPENSATION LAW AND MUST BE FILED WITH CARRIER IMMEDIATELY. FINAL REPORT Q PRINT OR TYPE MWCC # CARRIER FILE # Failure to submit this report will jeopardize payment of fees. EMPLOYEE (NAME AND ADDRESS - INCLUDE CITY, STATE and ZIP) SOCIAL SECURITY NUMBER DATE OF BIRTH AGE SEX DATE OF INJURY DATE DISABILITY BEGAN EMPLOYER (NAME AND ADDRESS - INCLUDE CITY, STATE and ZIP) INSURANCE CARRIER (NAME AND ADDRESS - INCLUDE CITY, STATE and ZIP) FEIN: FEIN: DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM (E) DIAGNOSIS CODE BY LINE) 1 2 3 4 (A) DATE(S) OF SERVICE (B) Place (C) Type (D) PROCEDURES, SERVICES OR SUPPLIES (E) DIAG (G) D AYS FROM TOof Serviceof Service(Explain unusual Circumstances) INCLUDE DRUGS PRESCRIBEDCODE(F) $ CHARGES OR UNITS S)RTOION (ALL REPGENERAL INFORMAT PATIENTS DESCRIPTION OF ACCIDENT OR OCCUPATIONAL ILLNESS HOSPITAL NAME/ADDRESS IF HOSPITALIZED NOTE ANY CHANGE IN DIAGNOSIS MADE ON ANY PREVIOUS REPORT AND EXPLAIN. SERVICES ENGAGED BY IF PATIENT HAS A PRIOR IMPAIRMENT CONTRIBUTING TO PRESENT DISABILITY, GIVEIS CONDITION WORK RELATED? IF SO, DESCRIBE DATE FIRST TREATMENT PARTICULARS. ROGRESSELIM./PRP EXPECTED DATE MMI DATE PATIENT REFUSED DATE PATIENT STOP TREAT. DATE DISCHARGED AS VOCATIONAL REHABILITATION WILL BE DATE ABLE TO RETURN WORK TREATMENT W/O ORDER CURED/MAX MED IMP. UNLIKELY PROBABLE NECESSARY Q LIGHT Q NORMAL IS PATIENT CAPABLE OF DOING SIMILAR/OTHER EMPLOYMENT AS BEFORE INJURED? IF NO, WHY? DOES PATIENT HAVE ANY PERMANENT DISABILITY RESULTING FROM THIS INJURY? IF SO, GIVE PART OF BODY AND PERCENT OF DISABILITY (INCLUDING VISION AND HEARING IF AFFECTED). _______ % PHYSICAL RESTRICTIONS, IF ANY RTOP RELFINA WAS THERE FACIAL OR HEAD DISFIGUREMENT? IF YES, DESCRIBE FULLY. DOCTORS NAME AND ADDRESS DOCTORS ID NUMBER DATE SIGNATURE ./ALLGEN MWCC Form B9,27 (6-96) AMPUTATION CHART ON BACK >>>> 2