State of Vermont HCP1(Revised 7/2013) Department of Labor Workers222 Compensation Division State File #: Ins. Co. File #: Health Care Provider Report Patient Information Employee Name: Date of Birth: Address: Phone Number: Employer at time of injury: Patient222s subjective complaint regarding this injury: Medical Information 226 Attach Additional Sheets if Necessary Date of Injury: Body Part and Nature of Injury: Date of Examination: Initial Visit Follow-up Visit Diagnosis/Medical Condition: This diagnosis/condition: is work related is not work related cause not yet determined Provider222s objective opinion regarding causal relationship: Have diagnostic tests been performed: Yes No Identify tests performed and results: Treatment Plan: Medications prescribed at this visit: Other medications patient is taking as a result of this injury: Work Capacity May return to work with NO RESTRICTIONS May not return to work May return to work with modified duty restrictions (see below) Restrictions: Health Care Provider Information Name: Address: Phone Number: Treatment Facility: Health Care Provider222s Signature Date Narratives/Test Results Attached: Yes No American LegalNet, Inc. www.FormsWorkFlow.com