COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 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 EVALUATION Plaintiff(s) APPOINTMENT : Calendar No. Date of Injury: MM : PA BWC Claim Number: JUDICIAL DD YYYY SUBPOENA (IF KNOWN) -against- : Employee First Name Index No. Employer Last Name : Name Street 1 Street 1 Street 2 Street 2 : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . State. . . . Zip. Code. . . . . . . . . . . . . . . .City/Town . .. . .. .... City/Town County Telephone State Zip Code County Telephone FEIN THE PEOPLE OF THE STATE OF NEW YORK Insurer or Third Party Administrator (if self-insured) TO Name Street 1 GREETINGS: Street 2 City/Town State Zip Code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Bureau Code , the Honorable 765 1297-1 at the Telephone Court located at County of County day of , 20 , at o'clock in the noon, and at any recessed DATEin room NOTICE:, on the OF THIS Claim Number FEIN or adjourned date, to testify DD give evidence as a witness in this action on the part of the and YYYY MM Attorney for Employee (if known) Attorney for Insurer/Employer (if known) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Name the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Firm Name Firm Name Name Street 1 Street 1 Witness, Honorable Street 2 Court in County, , one of the Justices of the day of City/Town State Telephone , 20 Zip Code PA Attorney ID Number Street 2 City/Town State Zip Code Telephone PA Attorney ID Number (Attorney must sign above and type name below) Attorney(s) for SEE IMPORTANT INFORMATION ON REVERSE. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: (OVER) LIBC-765 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. LIBC-765 : Calendar No. Important Notice: Section 306(a.2) of the Pennsylvania Workers' Compensation Act provides that an insurer (employer) : may request a workers' compensation claimant, on total disability status, to attend a medical examination to determine the JUDICIAL SUBPOENA Plaintiff(s) degree of their impairment due to the compensable injury. This examination should normally occur after the expiration of 104 weeks of total disability. The purpose-againstof the examination is to determine the degree of impairment using the American : Medical Association "Guides to the Evaluation of Permanent Impairment". If this evaluation results in an impairment rating of less than 50%, your benefits status will change to "partial disability" which has a 500 week duration limit. The amount of : wage loss compensation checks you are receiving is not affected by this change in status. If this evaluation is requested and scheduled within 60 days of the end of the 104 week period and results in a change to partial disability status, the effective : date of that change is at the end of the 104 weeks. If the evaluation is initially scheduled more than 60 days after the end of the 104 weeks, any resulting change in status occurs on Defendant(s) medical evaluation or as determined by the the date of the : evaluating physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... Prior to your receiving this form, you or your attorney (if appropriate) may have been contacted regarding your agreement to the selection of an impairment rating physician. An option also exists that the Department of Labor and Industry may have been requested to assign an impairment rating physician. THE PEOPLE OF THE STATE OF NEW YORK If you fail to attend the impairment rating evaluation, your workers' compensation benefits may be suspended (stopped) through the decision of a Workers' Compensation Judge. TO Your 104 weeks period of total disability status ended on MM DD . YYYY GREETINGS: You have been scheduled for a medical examination with Dr. NAME WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the who is located at: ¨ Please report to this office at TIME AM ¨ PM on . MM DD YYYY Your failure The doctor has been selected: to comply with this subpoena is punishable as a contempt of court and will make you liable to ¨ through mutual agreement of parties. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. by the Department of Labor and Industry, Bureau of Workers' Compensation. ¨ Please be prompt in arriving for this examination. You will be advised by an official notice of the results of the evaluation. Witness, Honorable Court in County, day of , 20 The parties in this matter have been served with a copy of this request. , one of the Justices of the (Attorney must sign above and type name below) Claim Representative Attorney(s) for First Name Last Name Signature Telephone Office and P.O. Address Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Telephone No.: Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of Facsimile No.: 1994. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com