IMPAIRMENT RATING DETERMINATION FACE SHEET examining physician222s completion of the electronic version of this form in WCAIS. EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER -- -- MM DD YYYY EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone ATTORNEY FOR EMPLOYEE (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number ATTORNEY FOR INSURER/EMPLOYER (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number EMPLOYER Name Address Address City/Town State ZIP Telephone FEIN SEE IMPORTANT INFORMATION ON THE REVERSE LIBC-767 REV 11-18 (Page 1) DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com I examined the referenced employee, , with regard to establishing an the provision of Section 306(a.3) of the Pennsylvania Workers222 Compensation Act. Attached is the Report of Medical Evaluation prepared as utilized by the American Medical Association Guides to the Evaluation of Permanent Impairment 6th edition (second printing April 2009). The original of this face sheet and report is being provided to the Bureau of Workers222 Compensation, Healthcare Services Review Division, 1171 S. Cameron Street, Harrisburg, PA 17104-2501, with copies to the employee, the employee222s attorney (if known) and the insurer within 30 days of the date of the impairment evaluation. Name of patient: Social Security number: XXX-XX-Date of birth: Date of this examination: Percentage of impairment rating: % My charge of $ examination. will be billed to the Insurer or Third Party Administrator (if self-insured) for conducting this approved board or its osteopathic equivalent, and that I have an active clinical practice of at least twenty (20) hours per week. Physician Name Address Address City/Town State ZIP Telephone Federal Tax ID number NPI# Specialty Contact Date of this noticeProvider or Representative222s signature -- MM DD YYYY Provider or Representative222s name (typed/printed) Telephone Email Employer Information Claims Information Services Hearing Impaired Email Services 717.772.3702 local & outside PA: 717.772.4447 *767*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBC-767 REV 11-18 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com