What is dwc 25

Name of Employer 8. Date of Reported Injury: The fact that a patient has been referred to a physician by an insurer for a reported work injury does not mean the identifiedclinical dysfu nction is causally related to the reported work incident.

Further, the fact that a physician has determined the initial injury to be work related does not necessarily mean that additional patient complaints or secondary symptoms are work related. Section I Clinical Assessment 9. Go to Section II Therefore, the phicianys shall apply requiremenpts ursuant to ss. No b Yes c If yes, specify below.

The Physician shall apply language found in 40ss. Yes a2 No b Do the objective relevant medical findings identified in Item 10c represent anacerbation tem ex porary worsening or aggravation progression of a pre-existing condition? Patient Classification: For this visit, the physician must identify the apprate leopri vel that accurately represents the patients status based upon objective relevant medical findings. Indicate the most appropriate level listed below. See instructions a Level I: Well defined, work-related medical conditioasson ciated with specific physiologic dysfunction s ; little or no discdanceor between physical findings and the medical complaint.

Go to Section III Based upon the preceding Clinical Assessment Items 10 13 appl, ying provisions under ss. Check appropriabote x and indicate specificity of services, frequency and duration in the section below. Physical Therapy, Chiropractic, Oteopathisc or comparable treatment 2. Fill out the form below to learn how our Forms Workflow solution can streamline your firm.

Treatment: interdisciplinary rehabilitation and management. No change in Items 20a - 20g since last report submitted. Check appropriate box and indicate specificity of services, frequency and duration below:. Assignment of limitations or restrictions must be based upon the injured employee's specific clinical.

However, the presence of objective relevant medical findings. No functional limitations identified or restrictions prescribed as of the following date:. Identify ONLY those functional activities that have specific limitations and restrictions for this.

Environmental Conditions: heat, cold, working at heights, vibration; Auditory; Specific Job Task s ; etc. NOTE: Any functional limitations or restrictions assigned above apply to both on and off the job activities, and are in. Patient has achieved maximum medical improvement? Guide used for calculation of Permanent Impairment Rating based on date of accident - see instructions :.

Is a residual clinical dysfunction or residual functional loss anticipated for the work-related injury? If any direct billable services for this visit were rendered by a provider other than a physician, please complete sections below:. Featured Tags Bill of Sale U. Please read before printing.

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