STATE OF NEW YORK - WORKERS' COMPENSATION BOARD PRACTITIONER'S REPORT OF FUNCTIONAL CAPACITY EVALUATION All reports are to be filed with the Workers' Compensation Board (see district office addresses on reverse), the workers' compensation insurance carrier, and if the patient is represented by an attorney or licensed representative, with such representative. If the patient is not represented, a copy must be sent to the patient. THIS EXAMINATION WAS REQUESTED BY: CARRIER/EMPLOYER ATTENDING PHYSICIAN DATE ATTENDING PHYSICIAN FOUND THAT CLAIMANT ACHIEVED MAXIMUM MEDICAL IMPROVEMENT ___________________ . ATTENDING PHYSICIAN MUST SET FORTH, IN WRITING, ANY RESTRICTIONS OR LIMITATIONS THAT THE CLAIMANT HAS WITH REFERENCE TO THE FUNCTIONAL CAPACITY EXAMINATION. IF NONE, THE ATTENDING PHYSICIAN MUST INDICATE SO. ATTACH SUPPORTING DOCUMENTATION. WCB CASE NO. CARRIER CASE NO. (IF KNOWN) DATE OF INJURY INJURED PERSON'S SOCIAL SECURITY NUMBER ADDRESS (Include Apt. No.) DATE OF EXAMINATION INJURED PERSON EMPLOYER INSURANCE CARRIER (First Name) (Middle Initial) (Last Name) The following eligibility criteria are required (check one): a. Claimant is preparing to return to a previous job, or b. Claimant has been offered a new job (verified), or c. Claimant is working with a rehabilitation provider and a vocational objective is established. If an entity other than the Employer/Carrier or Attending Physician has arranged for the Functional Capacity Examination, please indicate the entity's name and address. Results of Examination (attach additional sheets, if necessary) I hereby certify that the claimant meets all of the requirements as indicated on the reverse of this form and this report is a full and truthful representation of my professional opinion with respect to the claimant's condition. __________________________________________________________ Practitioner's Name __________________________________________________________ Practitioner's Signature __________________________________________________________ __________________________________________________________ Practitioner's License Number Date NO PRACTITIONER EXAMINING OR EVALUATING A CLAIMANT UNDER THE WORKERS' COMPENSATION LAW NOR ANY SUPERVISING AUTHORITY OR PROPRIETOR NOR INSURANCE CARRIER OR EMPLOYER MAY CAUSE, DIRECT OR ENCOURAGE A REPORT TO BE SUBMITTED AS EVIDENCE IN WORKERS` COMPENSATION CLAIM ADJUDICATION WHICH DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF THE EXAMINING PRACTITIONER. SUCH AN ACTION SHALL BE CONSIDERED WITHIN THE JURISDICTION OF THE WORKERS` COMPENSATION FRAUD INSPECTOR GENERAL AND MAY BE REFERRED AS A FRAUDULENT PRACTICE. FCE-4 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com NEW YORK WORKERS' COMPENSATION PHYSICAL MEDICINE FEE SCHEDULE 14. FUNCTIONAL CAPACITY EVALUATIONS Indications The FCE is utilized for the following purposes: 1. To determine the level of safe maximal function at the time of maximum medical improvement. 2. To provide a pre-vocational baseline of functional capabilities to assist in the vocational rehabilitation process. 3. To objectively set restrictions and guidelines for return to work. 4. To determine whether specific job tasks can be safely performed by modification of technique, equipment, or by further training. 5. To determine whether additional treatment or referral to a work hardening program is indicated. 6. To assess outcome at the conclusion of a work hardening program. General Requirements 1. The FCE may be prescribed only by a licensed physician in NYS, or may be requested by the carrier when indicated. 2. The FCE does not require prior authorization by the carrier. 3. The attending physician must justify the indication for each at the request of the carrier (see Eligibility Criteria). 4. The FCE shall be performed by a physical or occupational therapist currently holding a valid license in NYS, or other licensed provider qualified by scope of practice. Constant supervision by the licensed provider is required. Specific Requirements 1. The FCE, when medically necessary and indicated, may be performed only at the point of maximum medical improvement in the opinion of the attending physician. 2. The FCE should not be prescribed prior to three (3) months post-injury unless there is a significant documented change in the claimant's status which justified earlier utilization. 3. The following eligibility criteria is required for all claimants: a. Claimant is preparing to return to previous job. b. Claimant has been offered a new job (verified). c. Claimant is working with a rehabilitation provider and a vocational objective is established. 4. Reports will include the following information: a. Patient demographics including work history. b. Indication for evaluation. c. Type of evaluation performed. d. Raw and tabulated data. e. Normative date values. f. Narrative cover sheet with recommendations. 5. The bill for services provided must be attached to the report to be processed by the carrier. 6. All evaluation tools must be standardized, and normative data and interpretive guidelines must be attached to the report. 7. Charges for psychometric testing performed as part of the FCE by providers other than psychologists or psychiatrists are inclusive and may not be billed separately. 8. Testing and/or treatment provided by licensed psychologists or psychiatrists must be performed in accordance with the Psychology or Medicine fee schedules, and should be billed separately. HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. All reports should be sent directly to the Workers' Compensation Board at the address listed below: NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 Statewide Fax Line: 877-533-0337 FCE-4 Reverse (1-11) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com