1. 2.
3. 4. 5.
6. Date of Accident: 7. Employer Name
8.
Initial visit with this physician?

9.
No change in Items 9 - 13d since last reported visit. If checked, GO TO SECTION II.
10.
a)
b) WORK RELATED
c) UNDETERMINED as of this date
11. Has the patient been determined to have Objective Relevant Medical Findings? Pain or abnormal anatomical findings, in
the absence of objective relevant medical findings, shall not be an indicator of injury and/or illness and are not compensable.

b) YES
c) UNDETERMINED as of this date
12.
13.
a) Is there a pre-existing condition contributing to the current medical disorder?
a
1
) NO
a
2
) YES
a
3
) UNDETERMINED as of this date
b)
or aggravation (progression) of a pre-existing condition?

b
2
) exacerbation
b
3
) aggravation
b
4
) UNDETERMINED as of this date
c)
c
1
) NO
c
2
) YES
d)



14. LEVEL I - Key issue: specific, well-defined medical condition, with clear correlation between objective relevant
15. LEVEL II -
16. LEVEL III -Key issue: poor correlation between patient's complaints and objective, relevant physical findings, indicating
both somatic and non-somatic clinical factors. Treatment: interdisciplinar
y rehabilitation and management.
17. LEVEL UNDETERMINED AS OF THIS DATE.
18. No clinical services indicated at this time.
19.
20.
a)
a
1
)
a
2
)
a
3
)
b)
c)
c
1
)
Physical/Occupational therapy, Chiropractic, Osteopathic or comparable physical rehabilitation.
c
2
)
Physical Reconditioning (Level II Patient Classification)
c
3
)
Interdisciplinary Rehabilitation Program (Level III Patient Classification)
d)
e)
f)
f
1
)
In-Office:
f
2
)
Surgical Facility:
f
3
)
Injectable(s) (e.g. pain management):
g)
d
2
) YES
d
4
) YES
d
6
) YES
physical findings and patients' subjective complaints. Treatment correlates to the specific findings.
Specific instruction(s):
Diagnostic Testing: (Specify)
*** THIS IS A PROVIDER'S WRITTEN REQUEST FOR INSURER AUTHORIZATION OF TREATMENT OR SERVICES. ***
Key issue: regional or generalized deconditioning (i.e. deficits in strength, flexibility, endurance, and
motor control. Treatment: physical reconditioning and functional restoration.
the treatment recommended (management/treatment plan)?
MANAGEMENT / TREATMENT PLAN
d
5
) NO
Physical Medicine. Check appropriate box and indicate specificity of services, frequency and duration below:
Attendant Care:
SECTION II PATIENT CLASSIFICATION LEVEL
The following proposed, subsequent clinical service(s) is/are deemed medically necessary.
Identify specialty & provide rationale:
Consultation with or referral to a specialist. Identify principal physician:
DME or Medical Supplies:
b
1
) NO
Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 1
Visit/Review Date: 5.
BEFORE COMPLETING THIS FORM, PLEASE CAREFULLY REVIEW THE INSTRUCTIONS BEGINNING ON PAGE 3
NOTE: Health care providers shall legibly and accurately complete all sections of this form, limiting their responses to their area of expertise.
FOR INSURER USE ONLY
Insurer Name:
SECTION I
NOT WORK RELATED
Diagnosis(es):
a) NO
Injury/ Illness for which treatment is sought is:
Date of Birth:Injured Employee (Patient) Name: Social Security #:
Form DFS-F5-DWC-25 (revised 1/31/2008) Page 1 of 2
CLINICAL ASSESSMENT / DETERMINATIONS
d
1
) NO
Pharmaceutical(s) (specify):
Surgical Intervention - specify procedure(s):
If YES or UNDETERMINED, explain:
Do the objective relevant medical findings identified in Item 11 represent an exacerbation (temporary worsening)
contribute more than 50% to the present condition and be based on the findings in Item 11.
Major Contributing Cause: When there is more than one contributing cause, the reported work-related injury must
If checked,
GO TO SECTION IV
a) NO b) YES
SECTION III
the reported medical condition?
the functional limitations and restrictions determined?
Are there other relevant co-morbidities that will need to be considered in evaluating or managing this patient?
Given your responses to the Items above, is the injury/illness in question the major contributing cause for:
d
3
) NO
If checked,
GO TO SECTION IV
REFERRAL & CO-MANAGE TRANSFER CARECONSULT ONLY
No change in Items 20a - 20g since last report submitted.
21
22.
23.
b) NO
e) f) No
25.

b) NO
Physician Specialty:
If any direct billable services for this visit were rendered by a provider other than a physician, please complete sections below:
Provider Signature:
Provider Name: Date:
Patient Name: D/A:
No functional limitations identified or restrictions prescribed as of the following date:
c) Undetermined at this time.
Use additional sheet if needed.
_________________.
as of the following date: ___________________.
Frequency & Duration
patient. Identi
fy joint and/or body part __________________________________. Use additional sheet if needed.
identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this
Load
Visit/Review Date:
Grasp
Kneel
Lift-floor > waist
Stand
Functional Activity
Bend
Carr
y
Climb
Squat
Other choices; Skin Contact/ Ex
posure; Sensory; Hand Dexterity; Cognitive; Crawl; Vision; Drive/Operate Heavy Equipment;
a) YES, Date:
COMMENTS:
Environmental Conditions: heat, cold, working at heights, vibration; Auditory; Specific Job Task(s); etc.
Twist
Walk
_
Other
Pull
Push
Reach-overhead
Sit
______________________________________________
27.
b) Other, specifya) 1996 FL Uniform PIR Schedule
a) YES
d) Anticipated MMI date cannot be determined at this time.
Future Medical Care Anticipated:
24. Patient has achieved maximum medical improvement?
Form DFS-F5-DWC-25 (revised 1/31/2008) Page 2 of 2
"I certify to any MMI / PIR information provided in this form.” regarding this patient, and have been shared with the patient."
Physician DOH License #:
Provider DOH License #:
(print name)
documentation regarding this patient, and have been shared with the patient."
“I hereby attest that all responses herein relating to services I rendered have been made, in accordance with the instructions as part of this
form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical
Physician Name:
(print name)
Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 2
NOTE: Any functional limitations or restrictions assigned above apply to both on and off the job activities, and are in
Specify those functional limitations and restrictions, in Item 23, which are permanent if MMI / PIR have been assigned in Item 24.
The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions
ROM/ Position & Other Parameters
does not necessaril
y equate to an automatic limitation or restriction in function.
dysfunction or status related to the work injury. However, the presence of objective relevant medical findings
effect until the next scheduled appointment unless otherwise noted or modified prior to the appointment date.
Lift-waist>overhead
The injured workers' functional limitations and restrictions, identified in detail below, are of such severity that he/she
Yes
“As the Physician, I hereby attest that all responses herein have been made, in accordance with the instructions as part of this form, to a
c) Anticipated MMI date:
Physician Signature:
Physician Group: Date:
SECTION VII ATTESTATION STATEMENT
Assignment of limitations or restrictions must be based upon the injured employee's specific clinical
SECTION IV FUNCTIONAL LIMITATIONS AND RESTRICTIONS
26.
% Permanent Impairment Rating (body as a whole) Body part/system: _____________________________
SECTION V MAXIMUM MEDICAL IMPROVEMENT / PERMANENT IMPAIRMENT RATING
_____
cannot perform activities, even at a sedentary level (e.g. hospitalization, cognitive impairment, infection, contagion),
Comments: __________________________________________________________________________________
________________________________
SECTION VI FOLLOW-UP
reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation
Is a residual clinical dysfunction or residual functional loss anticipated for the work-related injury?
Guide used for calculation of Permanent Impairment Rating (based on date of accident - see instructions):
Next Scheduled Appointment Date & Time: 28.
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