The purpose of this form is to get a complete update on the treatment you received since the date of your accident or injury.
The first box asks for the insurer (the employer’s insurance company for the workers’ compensation claim). Boxes 2 through 7 ask for the employee’s information and information about the accident.
Section 1: Clinical Assessment/Determinations
You may skip this section and move on to section II if there were no changes to your treatment. However, if there were current changes to your treatment (during the time you are filling out this form), leave this box unchecked and continue to the next numbered line.
In this section, you will also identify if your treatment for the injury/illness is work-related.
Next, you are asked if the medical findings are objective. In other words, are your physician’s findings verifiable through diagnostic tests and physical examinations? Within these findings, there is little-to-no room in questioning these medical findings.
You will then explain if the medical findings are objective or undetermined. This information can be found in your medical records, where you can copy the answer directly onto this section. Your diagnoses (which can also be found in your medical records) can be copied onto this section as well.
Section II: Patient Classification Level
In this section, identify the patient classification level. Each level represents the key issues related to your medical records.
Section III: Management/Treatment Plan
This section on treatment, testing, prescriptions written, referrals, and diagnoses from your injury/illness is to be completed by your doctor or doctor’s office
Section IV: Functional Limitations and Restrictions
This section outlines what you can and can not do as a result of the injury or illness. Specifically, you are asked if you have been limited in your abilities because of the injury or illness and how severe the limitation is.
The chart then specifies types of functions, what you can sustain during that activity, and for how long.
Section V: Maximum Medical Improvement/Permanent Impairment Rating
This section asks if you have reached the peak of improvement for your injury/illness, when that peak was reached, the percentage of improvement, and what body part has reached that peak.
Section IV: Follow-Up
Here, you will provide the date and time of your next doctor visit.
Section IV: Attestation Statement
The doctor will complete this section and include his/her signature, confirming that the information on this form is correct.