1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 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 DOCTOR’S REPORT OF INJURY CLAIMS DIVISION SFN 10015 (5/2006) PLEASE PRINT OR TYPE USING BLACK OR BLUE INK PART 1 Injured Worker: Please Complete this section. Claim Number Social Security No. Injury Date Birth Date Sex F Part of Body Injured Time of Injury AM PM Injured Worker’s Phone Number Injured Worker’s Name Single Married Employer's Phone Number Employer’s Name Injured Worker’s Address Marital Status M Employer’s Address PART 2 Medical provider: Complete this form upon each examination. Date and Time of Appointment Purpose Initial Evaluation Re-check Discharge Any reported pre-existing/associated conditions? Yes No If yes, please explain: ____________________________________ _____________________________________________________ Diagnosis/condition based upon objective medical findings: Diagnosis code: Does mechanism of injury coincide with finding? Yes No Injured Worker’s Description of Injury ______________________________________________ _____________________________________________________ ______________________________________________ _____________________________________________________ ______________________________________________ Date injured worker may return to work Return to work without work restrictions Physical Demand Level with the following work restrictions (list) Occasional (0-3 Hours) Frequent (3-6 Hours) Constant (6-8 Hours) Sedentary 10 lbs. Light 20 lbs. Medium 50 lbs. Negligible 10 lbs. And/or Walk/Stand/Push/Pull of Arm/Leg controls 20 lbs. Negligible Negligible and/or Push/Pull of Arm/Leg controls while seated. 10 lbs. Heavy 70 lbs. 50 lbs. 20 lbs. (Lifting) Other instructions and/or limitations including prescribed medications or PT order: ________________________________________ _________________________________________________________________________________________________________ Prognosis and anticipated length of medical treatment:______________________________________________________________ The above restrictions are in effect until (date) . Re-evaluation date: Time: Has injured worker reached maximum medical improvement? Yes No If yes, date MMI reached If no, explain Will any permanent injury result from the worker’s injury? Yes No Unknown If yes, is it at least 16% whole body according to the current edition of AMA Guides to the Evaluation of Permanent Impairment? Yes Comments: No 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 Address Date Physician’s Signature Physician’s Phone No. Injured Worker’s Signature Date Physician’s Fax No. Physician’s Federal Tax ID No. 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. Please have your doctor complete, sign, and return this form to WSI immediately. Prompt payment of compensation depends on this form. C3 American LegalNet, Inc. www.FormsWorkflow.com 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. American LegalNet, Inc. www.FormsWorkflow.com