BI-214 01/06 Return completed form to: Diagnosis Update BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 THIS FORM IS INTENDED FOR USE BY THE PHYSICIAN OF RECORD TO UPDATE APPROPRIATE DIAGNOSTIC INFORMATION. SIGN, DATE THE FORM AND RETURN THE FORM. COMPLETE CLAIMANT AND PHYSICIAN INFORMATION. LIST ICD9-CM CODES IN ORDER OF SEVERITY WITH CORRESPONDING DESCRIPTIONS. SHOW CLINICAL FINDINGS UPO N WHICH THE DIAGNOSIS IS BASED. 1. Claimant Name: 2. Claim Number: 5. Treating Physician Name and Address: 3. Social Security Number 4. Date of Injury 6. ICD9 - CM Diagnosis Numerical Code(s) 1. Primary: 2. Secondary: 3. Secondary: 4. Secondary: 7. Physician's FEIN: 8. Diagnosis Description: 1. Primary: 2. Secondary: 3. Secondary: 4. Secondary: 9. Provide clinical findings on which current diagnosis is based and advise how the present condition relates to the compensable injury. 10. Physician Signature: 11. Date: BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332 American LegalNet, Inc. www.USCourtForms.com