INJURY NUMBER MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS MEDICAL TREATMENT FORM NOTE: THIS FORM MUST BE TYPED OR HAND PRINTED IN BLACK INK. P.O. Box 58 Jefferson City, MO 65102-0058 www.labor.mo.gov/DWC INJURED WORKER INFORMATION 1. NAME OF INJURED PERSON Last 4. NAME OF EMPLOYER First 2. SOCIAL SECURITY NUMBER 3. DATE OF INJURY - - 5. NAME OF INSURANCE CARRIER 6. DESCRIPTION OF HOW INJURY OCCURRED AS RELATED BY INJURED PERSON 7. DATE OF FIRST TREATMENT 8. BODY PART TREATMENT INFORMATION 9. DESCRIBE TREATMENT GIVEN BY YOU 10. DID EMPLOYEE HAVE SURGERY? Yes 11. HOSPITALIZATION? No Yes No IF "YES," PROVIDE NAME AND ADDRESS OF HOSPITAL Admission Date Discharge Date 12. PHYSICAL REHABILITATION PRESCRIBED? 13. REFERRAL TO ANOTHER DOCTOR? Yes No IF "YES," NAME AND ADDRESS Yes No RETURN TO WORK INFORMATION 14. DATE LOST TIME BEGAN FROM WORK 15. DATE RELEASED TO RETURN TO WORK RELEASED TO RTW WITHOUT PHYSICAL RESTRICTIONS RELEASED TO RTW WITH PHYSICAL RESTRICTIONS PERMANENT RESTRICTIONS TEMPORARY RESTRICTIONS ­ DURATION 16. IS ADDITIONAL MEDICAL TREATMENT NEEDED? DESCRIBE THE RESTRICTIONS Yes No IF "YES," PROGNOSIS 17. NEXT APPOINTMENT DATE 18. DOCTOR'S RATING IF ANY: % $ (percentage) OF THE (body part) AT THE (week level). 19. TOTAL COST OF MEDICAL IS THE FINAL COST. Yes No PHYSICIAN INFORMATION 20. PHYSICIAN NAME (Type or Print) Last 22. PHYSICIAN ADDRESS First CITY STATE ZIP CODE 21. LICENSE NUMBER 23. PHYSICIAN SIGNATURE 24. TELEPHONE NUMBER 25. DATE ( ) - ATTACH A BRIEF NARRATIVE WITH THE FINAL REPORT, IF APPROPRIATE. The Division defines a "brief narrative" as the following "not to exceed a maximum of five (5) pages describing the course of treatment, the diagnosis, the evaluation for permanent injury and the need for future medical treatment, if any." WC-9 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com