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.