BI-219a 01/06 Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 Notice of Maximum Medical Improvement TO BE COMPLETED BY THE AUTHORIZED TREATING PHYSICIAN UPON THE CLAIMANT OBTAINING MAXIMUM MEDICAL IMPROVEMENT. 1. Claimant’s Name and Address 2. Claim No. S. S. No. D. O. I. 3. Are you the claimant’s authorized treating physician in this claim? Yes No 4. Present diagnosis: COMPLETE ALL OF THE QUESTIONS. PLEASE PRINT OR TYPE. 5. Is further treatment necessary? Yes No If yes, please list the type of treatment required. 6. Claimant was/will be able to return to work on (date): / / 7. Has claimant reached a maximum degree of medical improvement in relation to this injury? 8. Is there a permanent partial disability as a result of this injury? Yes Yes No No If yes, please give your opinion of the degree of Permanent Partial Disability in terms of percentage of whole man. 9. Is any part of the permanent disability listed under Question 8 due to causes other than this injury? % Yes No If yes, please allocate any disabilities resulting from prior claims and noncompensable injuries and/or disease processes. 10. If you have recommended a percentage of permanent partial disability (Question 8), please list the physical findings on which the assessment was made including any restrictions on the claimant’s functional abilities. A narrative report should be attached if indicated. 11. Date of examination upon which these findings are based: / / 12. Physicians Name, Address and Telephone No. Physician’s Signature FEIN: Date BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.USCourtForms.com