1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 CLAIMS DIVISION BISMARCK ND 58506-5585 SFN 58550 (05/2008) Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com PLEASE TYPE OR PRINT USING BLACK OR BLUE INK. SEE REVERSE FOR ADDITIONAL INSTRUCTIONS. Claim Number Injury Date Birth Date Social Security Number General Information CAPABILITY ASSESSMENT Injured Worker’s Name Employer’s Name Injured Worker’s Address Injured Worker’s Phone Number Diagnosis Code/ICD9 Code Medical Assessment Employer’s Phone Number Visit Date Part of Body Injured Purpose: Initial Evaluation Re-check Discharge If this is the initial evaluation, please complete the next question. Yes No Any reported pre-existing/associated conditions? Injured worker is released to work with: No restrictions With the following restrictions (If so, please complete below) Restrictions are in effect until___________________________ Restrictions ordered are in effect for home and/or work activity. Doctor’s Estimate of Physical Capabilities Physical Capabilities (Related to work injury): Not Recommended Sit Stand / Walk Climb (ladders/stairs) Twist Bend / Stoop Squat / Kneel Crawl Reach (Left, Right, Both) Work above shoulders (L, R, B) Wrist (L, R, B) Grasp (L, R, B) Fine Manipulation (L, R, B) Operate foot controls (L, R, B) Drive / Operate Machinery Lifting/Pushing Not Recommended Lift (L, R, B) lbs Seldom 1-5% Seldom lbs Occasional 6-33% Occasional lbs Frequent 34-66% Constant 67-100% Frequent lbs Constant lbs Carry (L, R, B) lbs lbs lbs lbs lbs Push / Pull lbs lbs lbs lbs lbs Other instructions and/or limitations: MMI Follow-up Restrictions based upon: Workability Functional Capacity Assessment Follow-up Plan Next visit with this provider:__________________ Referral to:_______________________ Physical Exam Medication Prescribed:_________________________ Other:_______________________________ Consult with:_____________________________ Has injured worker reached maximum medical improvement (MMI)? Yes No Date_________________ If yes, is it likely that the permanent partial impairment (PPI) will be greater than 16% whole body? Yes No Unknown FRAUD WARNING – By signing this form, I acknowledge that I have read the Fraud Warning on the reverse side of this form and understand that falsifying this claim or making a false statement regarding this claim may be a felony punishable by substantial fines and imprisonment. By my signature below, I declare that the statements on this form are true and accurate. Physician’s Signature Injured Worker’s Signature Facility Federal Tax ID Date Phone Number I authorize the release of this report and any other medical information related to my claim to my employer, Workforce Safety & Insurance (WSI) and its agents. C3 Please complete sign, and return this form to WSI immediately. Prompt payment of compensation depends on this form. American LegalNet, Inc. www.FormsWorkFlow.com Important Notes Complete a C3 form whenever restrictions are needed for return to work. For subsequent visits, a C3 form should be completed when there are meaningful changes in restrictions. This information will assist employers in determining appropriate accommodations. Keeping a worker on the job in transitional duty reduces the worker’s likelihood of long-term disability. Please return the original form to WSI, provide a copy for the injured worker to give to their employer, and retain a copy for your records. Completion of the C3 is not a substitute for chart notes. Notes (e.g., SOAP format) are needed for continued management of the claim as well as for payment of services. All medical documentation, including the new C3 forms, should continue to be faxed to 1-888-786-8695 or 1-701-328-3820. Completing the C3 Form General Information Section It is imperative providers indicate the injured worker’s claim number on the C3 form. A claim number can be obtained by visiting www.WorkforceSafety.com (Click on “Find a claim number”). If a claim has not been filed, the injured worker must complete a First Report of Injury. The C3 form cannot be used to file a claim. • Work Activity Section It is only necessary to indicate the applicable physical demands that must be restricted. Those left blank will be considered as unrestricted. • Restrictions established are applicable 24 hours a day and not just at work. • Writing “See Chart Notes” on the C3 form is not appropriate because chart notes typically arrive later in the claim file than the C3 and are not immediately available to employers. • MMI Section This information helps WSI assess eligibility for benefits. o Maximum medical improvement (MMI) refers to a treatment plateau in a person’s healing process. It can mean the injured worker has fully recovered from the injury or the medical condition has stabilized to the point that no major medical improvement can be expected. o Providers are requested to provide an opinion regarding permanent partial impairment (PPI) versus actually determining the degree or extent of impairment according to a rating schedule. • Fraud Warning for Filing False Claims Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers’ compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with the Fund, including injured workers, employers, medical providers, and attorneys. 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