COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 Social Security Number: ________ - _______ - _________ IMPAIRMENT RATING DETERMINATION FACE SHEET Employee Date of Injury: ______/______/____________ MM DD YYYY PA BWC Claim Number: ____________________________ (IF KNOWN) Employer First Name Last Name Name _________________________________ _____________________________________________ _________________________________________________________________________________ Street 1 Street 1 _________________________________________________________________________________ _________________________________________________________________________________ Street 2 Street 2 _________________________________________________________________________________ _________________________________________________________________________________ City/Town City/Town State Zip Code State Zip Code ________________________________________________ _________ ____________-_________ ________________________________________________ _________ ____________-_________ County Telephone County __________________________________________ (_______) _______ - _______________ ____________________________________________ Telephone FEIN (_______)_______-____________________________ _____________________ Insurer or Third Party Administrator (if self-insured) Name _________________________________________________________________________________ 767 0506 Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town State Zip Code ________________________________________________ _________ ____________-_________ Telephone Bureau Code (_______) _______-___________________________ _____________________ County DATE OF THIS NOTICE: ____________________________________________ ______/______/___________ MM DD YYYY Claim Number Attorney for Employee (if known) FEIN ____________________________________________ _____________________ Attorney for Insurer/Employer (if known) Name Name _________________________________________________________________________________ _________________________________________________________________________________ Firm Name Firm Name _________________________________________________________________________________ _________________________________________________________________________________ Street 1 Street 1 _________________________________________________________________________________ _________________________________________________________________________________ Street 2 Street 2 _________________________________________________________________________________ _________________________________________________________________________________ City/Town City/Town State Zip Code State Zip Code ________________________________________________ _________ ____________-_________ ________________________________________________ _________ ____________-_________ Telephone PA Attorney ID Number Telephone PA Attorney ID Number (_______)_______-____________________________ ________________________________ (_______)_______-____________________________ ________________________________ Claim Representative SEE IMPORTANT INFORMATION ON REVERSE. First Name Last Name _________________________________ _____________________________________________ Telephone (_______) _______ - _______________ (OVER) LIBC-767 REV 5-06 (Page 1) American LegalNet, Inc. www.FormsWorkflow.com I examined the referenced employee, ________________________________________________________, with regard to establishing an Impairment Rating Determination to define the degree of impairment due to the compensable injury, if any, in accordance with the provision of Section 306(a.2) of the Pennsylvania Workers’ Compensation Act. Attached is the Report of Medical Evaluation prepared as utilized by the most recent edition of the American Medical Association Guides to the Evaluation of Permanent Impairment. The original of this face sheet and report is being provided to the Bureau of Workers’ Compensation, 1171 S. Cameron Street, Room 103, Harrisburg, PA 17104-2501, with copies to the employee, the employee’s attorney (if known) and the insurer within 30 days of the date of the impairment evaluation. Name of Patient: _________________________________________________________ Social Security Number: ______-_____-__________ Reported Date of Injury: ______/______/___________ MM Date of this Examination: DD YYYY ______/______/___________ MM DD YYYY Percentage of Impairment Rating: _________% My charge of $_________________ will be billed to the Insurer or Third Party Administrator (if self-insured) for conducting this examination. I attest that I am a physician licensed in the Commonwealth of Pennsylvania and certified by an American Board of Medical Specialties approved board or its osteopathic equivalent, and that I have an active clinical practice of at least twenty (20) hours per week. Physician First Name Last Name _________________________________ _____________________________________________ Signature _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town State Zip Code ________________________________________________ _________ ____________-_________ Telephone (_______) _______-___________________________ Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-767 REV 5-06 (Page 2) American LegalNet, Inc. www.FormsWorkflow.com