Rev. 10/17 1 NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION FORM LETTER TO HEALTH CARE PROVIDER INSTRUCTIONS: Please fill out and return this form promptly. Base your answers on a reasonable medical probability. Answer all questions which you believe to be pertinent to the Worker222s claim. Please give one copy of the form to the Worker. The maximum allowable fee for completion of this form is set forth in the health care provider fee schedule. The bill for completion of this form should be sent to the claims administrator. Return this completed form letter to: Name: Address: TO: Health Care Provider: Name: Address: RE: Worker: Name:WCA# Last, First DOB: SSN (last four digits): XXX-XX- 1.Date of Injury/Occurrence: 2.Date that the Worker was first seen/treated: 3.Date that the Worker was last seen/treated: 4. Diagnosis of the condition(s) for which you have treated the Worker: 5.In your opinion, are the conditions or complaints for which you have treated the Worker causally-relatedto an on-the-job injury or exposure? YES NO6.Is the Worker able to return to work? YES NOIf no, when do you anticipate return to work? 7.Indicate the period of time, if any, the Worker has been unable to work: 8. Has the Worker reached maximum medical improvement (MMI)? YES NO a.Date of MMI:b.Anticipated date of MMI:9.If the Worker has reached MMI and you have already assessed Worker222s impairment, please indicate youropinion as to the percentage of the Worker222s anatomical or functional abnormality as of the date of MMI:a.Percentage of impairment, if any b.Whole body or body part: c.Indicate which edition of AMA Guides used: d.AMA page numbers: American LegalNet, Inc. www.FormsWorkFlow.com Rev. 10/17 2 10.Has a physical capacities assessment of functional capacity evaluation been performed? YES NOPerformed by: Date of evaluation: 11.Does the Worker have work restrictions? YES NOIf yes, please indicate any work restrictions on the chart below: Never Occasionally Frequently Lift over 50lbs Lift up to 50 lbs. Lift up to 25 lbs. Lift up to 20 lbs. Lift up to 10 lbs. Lift up to 5 lbs. Walking Standing Sitting Push / Pull ARM Controls Push / Pull LEG Controls 12.Are the above stated work restrictions permanent? YES NOIf no, how long do you anticipate the Worker will have the stated restrictions? 13.Does the Worker have activity restrictions? YES NO If yes, please describe any additional activity restrictions: 14. Have you referred the Worker to other health care providers, hospitals or institutions? YES NO If yes, please provide name(s): 15.Other remarks: I hereby affirm that the foregoing responses or opinions are true and correct to a reasonable medical probability. Physician222s signature: Date: Physician222s printed name: Address: City/State/Zip: Telephone: American LegalNet, Inc. www.FormsWorkFlow.com