Employer Insurance Company Date of Birth Clinic/Facility Name/Address Primary Treating Provider Visit Date Provider Phone 468Left Right lbs. lbs. lbs.Left Right lbs. lbs. lbs.Left Right lbs. lbs. lbs.Left Right lbs. lbs. lbs.Left Right lbs. lbs. lbs. 0 2 4 6 8 Sit/stretch breaks of (# of times) per In extreme hot/cold environments, hours/day allowed On uneven surfaces, hours/day allowed At heights/scaffolding, hours/day allowed No driving/operating heavy equipment Can only drive automatic transmission Must wear splint/cast at workLeft Right Must use crutches at all timesLeft Right Must keep elevatedLeft Right No skin contact with: Left Right Dressing changes necessary at workLeft Right Left Right Meds restrict ability to work safely (explain restrictions below)Left Right Psychological restrictions evident (explain restrictions below) 0 2 Other Status from (start date): to (end date): Status from (start date): to (end date): Status from (start date): to (end date): lbs. lbs. Other Expected follow-up services (check all that apply and indicate dates if known) : Next evaluation by treating provider on (date) at (time) Referral to / Consult with (provider name and specialty) Physical / Occupational therapy / Chiropractic / Osteopathic Rehabilitation / Reconditioning x/week for weeks Other treatment / Follow-up Worker fully discharged from care. This is the last scheduled visit for this problem. Maximum medical improvement (MMI) indications (check only one and indicate the date) : Worker has reached MMI on(date). Permanent impairment rating (% / body part Not at MMI but anticipated on (date) Worker Name (Last, First) SSN-last 4 digits xxx-xx- Date of Injury Pull After evaluation, I recommend this worker be (check only one option) : Released to hours and tasks routinely performed on the job held at the time of injury. SKIP TO SECTION 4 TREATMENT/FOLLOW-UP The worker is not capable of performing ANY work activities at this time. SKIP TO SECTION 4 TREATMENT/FOLLOW-UP Released to work, subject to the following restrictions in Section 3 ACTIVITY RESTRICTIONS (Blank items indicate no restriction) lbs. lbs. lbs. lbs. lbs. lbs. lbs. lbs. Visit Type: Initial Follow-up - For follow-ups, is there a change in recommendation since last visit? YES NO Kneel / Squat Bend / Stoop Twist Walk Climb (stairs/ladder) Reach below shoulder NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION PROVIDER'S REPORT OF PHYSICAL ABILITY Miscellaneous Restrictions (if any) 3 2 1GENERAL INFORMATION WORK STATUS ACTIVITY RESTRICTIONS (If YES, please fill out all sections on the remainder of this form. If NO, you may skip to Section 4 TREATMENT/FOLLOW-UP) Medication Restrictions (if any) Psychological Restrictions (if any) Posture / Motion Restrictions (if any) Maximum cumulative hours/day Stand Sit Grasp / Squeeze Wrist (flex/extension) Fine manipulation Operate foot controls Reach above shoulder Other: Provider Signature: Date: 4 - Important note to worker: The restrictions indicated below should be followed outside of work as well as at work - Lift / Carry / Push / Pull Restrictions (if any) Maximum cumulative hours/day Lift from the floor Lift from waist height Carry Push OTHER RESTRICTIONS/MODIFICATIONS (be specific) : TREATMENT / FOLLOW-UP Max hours per day of work: Keyboard American LegalNet, Inc. www.FormsWorkFlow.com NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION PROVIDER'S REPORT OF PHYSICAL ABILITY INSTRUCTIONS / DEFINITIONS INFORMATION FOR HEALTH CARE PROVIDERS (HCPs): Purpose of this form: Because a prolonged workplace absence is detrimental to a worker222s well-being, the WCA asks that you facilitatethe injured worker222s safe, efficient returntowork by providing interested parties a clear, quantitative description of current claim-related physical restrictions. In this way, you help employers identify suitable work and assign safe work activities This report as part of your evaluation: The WCA Health Care Provider Fee Schedule & Billing Instructions (HCP Fee Schedule) referencesthis report. Note - completion is included as part of the HCP222s service and shall not be billed as a separate line item When / who fills this form out: Based on a reasonable medical probability, you as the primary treating HCP should fill this report out ateach appointment. Note - This form is not intended to substitute a Functional Capacity Evaluation (FCE) After you fill this report out: Provide a copy to the worker immediately after each office visit. The worker should then provide a copy totheir employer who will then forward to the appropriate claims administrator CARE PROVIDERS (HCPs) DEFINITIONS OF PHYSICAL CAPACITY LEVELS (for reference only): Sedentary - Ability to lift up to 10 lbs. occasionally or 5 lbs. frequently with sitting, walking/standing necessary to carry out duties Light - Ability to lift up to 20 lbs. occasionally or 10 lbs. frequently, significant standing/walking or sitting with pushing/pulling of arm/leg Medium - Ability to lift up to 50 lbs. occasionally or up to 25 lbs. frequently Heavy - Ability to lift up to 50 lbs. occasionally or up to 50 lbs. frequently INSTRUCTIONS: 1. GENERAL INFORMATION:: Fill out worker222s name, last 4 digits of SSN, date of birth, date of Injury, visit date, employer name, your clinicor facility name and address, insurance company/carrier name, your name as the primary treating HCP, your phone number a. Visit Type: Indicate if this is an initial or follow-up visit for this worker regarding this workers222 compensation injury/illness b. For Follow-ups only: Check either YES or NO to indicate if you are making ANY change in recommendation since the last visitb1. If you check YES to indicate either a work status or activity restriction change, fill out the remainder of this report in its entiretyb2. If you check NO to indicate no change since the last visit in either work status or ANY of the activity restrictions, you can foregofilling out Section 2 WORK STATUS and Section 3 ACTIVITY RESTRICTIONS. Skip to Section 4 TREATMENT/FOLLOW-UP. Sign/date 2. WORK STATUS: : Check the appropriate option box to indicate if the medical condition(s) resulting from this workers222 compensationinjury/illness will allow for this worker to returntowork in some capacity. For each option, indicate the start and anticipated end dateof your current work status recommendation. If it is permanent, you can write that in. Note: DO NOT check more than one box. a. Option 1 226 Check this box to release the worker to regular work with no restrictions. Do not fill out Section 3 ACTIVITYRESTRICTIONS. Skip to Section 4 TREATMENT/FOLLOW-UP and sign/date b. Option 2 226 Check this box if you recommend NO work at all be performed at this time. Do not fill out Section 3 ACTIVITYRESTRICTIONS. Skip to Section 4 TREATMENT/FOLLOW-UP and sign/date c. Option 3 226 Check this box if you feel the worker can return to work in a modified duty capacity with restrictions. Fill out Section 3ACTIVITY RESTRICTIONS to indicate all the applicable restrictions as well as Section 4 TREATMENT/FOLLOW-UP and sign/date 3. ACTIVITY RESTRICTIONS:: Fill this section out only if you checked 223Option 3 226 Released to modified duty224 in the previous sectionNote: If a particular restriction does not apply, leave it blank. All unmarked items are considered no restrictions a. Lift / Carry / Push / Pull Restrictions For each activity listed that you are restrictinga1. Check 223Left or 223Right224 if limitation is to just one side. For bilateral restrictions, check both 223Left224 AND 223Right224a2. Under the maximum cumulative hours/day allowed, write the maximum number of pounds the worker can handlea3. Under Other, indicate further instructions beyond the maximum cumulative hours/day allowed, if appropriate 226 Note re lifting restrictions: If you are restricting lifting from the floor, indicate if lifting from waist height is also restricted b. Posture / Motion Restrictions For each activity listed that you are restrictingb1. Where applicable, check 223Left or 223Right224 if limitation is to just one side. For bilateral restrictions, check both 223Left224 AND 223Right224b2. Under the maximum cumulative