BI-219 09/07 Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 Attending Physician’s Report Physician must complete all boxes legibly (85-20.3.11) Failure to complete all boxes legibly may result in delay of benefits. Claim Number Social Security Number DOI Phone Number Claimant Name Current Address Has your address changed? Yes No Has your phone number changed? Yes No If yes to either, please enter the new address or phone number. 1. Date of Examination 2. Date of Next Appointment 3. Accepted Diagnosis Additional Requested Diagnosis (please attach justification) 4. Claimant Occupation 5. Treatment Plan Information (please include medication, consultations, complicating conditions, subjective complaints, objective findings) Please attach treatment notes, if available. Has an FCE been scheduled? Yes No IME Recommended? 6. Please indicate which of these activities the claimant CAN perform. Sitting Yes No Standing Yes No Walking Yes No Kneeling Yes No Twisting Yes No 7. Restrictions limited to: Yes No Anticipated MMI Date Driving Reaching Bending Climbing 8. Dates claimant is certified temporarily and totally disabled due to compensable injury From To Estimated Trial RTW Date Yes Yes Yes Yes No No No No Modified Duty RTW Date 9. Physician legal signature Physician printed name Physician Address I certify this document has been discussed with me and I understand the treatment plan and work restrictions. I [ ] have [ ] have not received any income for any work during the time I have been certified temporarily and totally disabled. I hereby certify that the statements and answers set forth above are true and correct to the best of my knowledge and belief. I am aware that the law provides severe penalties if I knowingly and with fraudulent intent withhold a material fact or make false statements in order to obtain or increase a benefit to which I am not entitled. Claimant printed name Date 10. C l a i m a n t s i g n a t u r e Date American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING THE BI-219 1. Date the treating physician treated/actually had face-to-face contact with the claimant regarding the compensable injury. This should be mm/dd/yyyy. 2. The next date the treating physician is scheduled to treat the claimant face to face for the compensable injury. This should be mm/dd/yyyy. 3. Treating Physician will need to complete. Diagnosis must relate to the mechanism of injury and compensable diagnosis. If additional diagnoses are being requested, the BI-214 must be completed. 4. Claimant’s current occupation. 5. Treatment plan box must be completed in addition to any attachments regarding treatment. These notes must include claimant’s subjective complaints, objective findings, the current assessment, and the treatment plan (detailed). It should also indicate if an FCE is warranted, an IME recommended, and anticipated MMI date. 6. Please mark Yes or No on activities claimant is physically able to perform with regard to the compensable diagnosis. 7. What physical limitations does the claimant have based only on the compensable injury. Please be specific. 8. This must indicate specific dates. “Unknown” or “indefinite” is not acceptable and will cause a delay in temporary total benefits. Temporarily and totally disabled is defined as being unable to perform any activities associated with the covered employment. Estimated trial return-to-work date is the date claimant is medically released to attempt full duty work with the pre-injury employer in the pre-injury job. Modified return-to-work date is the date claimant may attempt to return to work with physician-approved modifications. 9. This is the physician’s signature and the physician’s printed name (must be legible). Per 85-20.6.1, disability dates must be certified by the treating physician only. Physician’s Assistants and Nurse Practitioners may not certify disability. 10. Claimant must sign form which indicates he/she agrees with the treatment plan and he/she has not received any other wages during the dates of disability certified by the treating physician. Note: If claimant has reached maximum degree of medical improvement, please complete form BI-219a, Notice of Maximum Medical Improvement. American LegalNet, Inc. www.FormsWorkflow.com