en-USJurisdiction Claim Number (JCN)en-USClaim Administrator Number en-USPatient222s Nameen-USName of Company/Employer Date of Injury/Occupational Disease Date of Amputation en-USInjured Worker Information en-USAmputation Chart - Hand/Foot Thumb en-USDistalen-USProximalen-USMetacarpalsen-USDistalen-USMiddleen-USProximalen-USIndex en-US(1st) en-USMiddle en-US(2nd)en-USRing en-US(3rd) en-USLittle en-US(4th) en-US1en-US2en-US3en-US4en-US5 1 en-US2en-US3en-US4en-US5en-USGreat en-USToeen-US2nden-US3rden-US4then-US5then-USI certify that I personally examined and treated this patient.en-USAddressen-USAttending Physician222s Name en-USAttending Physician en-USWhich hand?en-USThe physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable.en-USWhich foot? en-USPhalangesen-USMetatarsalsen-USSIGNATURE OF PHYSICIAN en-USDATE en-USAmputation Chart en-USToll-Free:en-US 1-877-664-2566 en-US| Online: en-USwww.workcomp.virginia.goven-US en-US| en-USMail:en-US en-US333 E. Franklin St., Richmond, Virginia 23219en-USRev.en-US 12/18en-USVirginia Workers222 Compensation Commissionen-USAccess your claim online: webfile.workcomp.virginia.gov City þ State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com en-USAmputation Chart Process & Instructions en-USAmputation Charten-USThe treating physician completes this form to provide information to support an injured worker222s claim which en-USen-USInstructionsen-USThe physician should complete this form with a straight line drawn at the exact point of amputation. Circles en-USare not acceptable. This will allow the Commission to determine an accurate entitlement of permanent partial en-USen-USen-US p en-US.vir g en-USinia. g en-USoven-US. en-USen-USmail or in-person at 333 E. Franklin St., Richmond, Virginia 23219.en-USFor questions or assistance with completing this form, please contact the Virginia Workers222 Compensation en-USCommission toll-free at 1-877-664-2566. en-USToll-Free:en-US 1-877-664-2566 en-US | Online: en-USwww.workcomp.virginia.goven-US en-US | en-USMail:en-US en-US333 E. Franklin St., Richmond, Virginia 23219 American LegalNet, Inc. www.FormsWorkFlow.com