Fillable Physician's Report of Workers' Compensation Injury (Colorado DORA)

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Physician's Report of Workers' Compensation Injury (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Physician's Report of Workers' Compensation Injury
A copy of this report must be sent to the injured worker and the insurer.
1. REPORT TYPE
Initial Progress Closing
EXAM DATE
2. CASE INFORMATION
Date of Injury Insurer Claim #
Injured Worker Insurer Name/TPA
Social Security # Insurer Phone/Fax
Date of Birth Employer Name
3. INITIAL VISIT (only)
a. Injured worker’s description of accident/injury
b. Are your objective findings consistent with history and/or work-related mechanism of injury/illness?
Yes No
4. CURRENT WORK STATUS
Working
Not Working
5. WORK-RELATED MEDICAL DIAGNOSIS(ES)
6. PLAN OF CARE
a. TREATMENT PLAN
Diagnostic tools/tests
Procedures
Therapy
Medications
Supplies
Other
b. WORK STATUS
Able to return to full duty on
Able to return to modified duty from to
Unable to work from to
Able to return to part time work on for hours per day
c. LIMITATIONS/RESTRICTIONS
No Restrictions Temporary Restrictions Permanent Restrictions
Lifting (maximum weight in pounds) lbs. Walking hours per day
Repetitive lifting lbs. Standing hours per day
Carrying lbs. Sitting hours per day
Pushing / Pulling lbs. Crawling hours per day
Pinching / Gripping Kneeling hours per day
Reaching over head Squatting
hours per day
Reaching away from body Climbing hours per day
Repetitive Motion Restrictions
Other
7.
FOLLOW UP CARE AND REFERRALS - *7c. requires a notice by certified mail to insurer & patient within 3 business days. (See Instructions)
a. Return Appointment Date
b. Referral for Treatment (specify) Evaluation (specify)
Impairment Rating Other (specify)
Referred Provider’s Name Phone #
c.
Discharged for Non-Compliance* Discharged from Care for Nonmedical Reasons*
8. MAXIMUM MEDICAL IMPROVEMENT (MMI)
Injured Worker has reached MMI Date of MMI
Injured Worker is not at MMI, but is anticipated to be at MMI in/on
MMI date unknown at this time because
9. MAINTENANCE CARE AFTER MMI
Yes No
If yes, specify care:
10. PERMANENT MEDICAL IMPAIRMENT (REQUIRED)
No permanent impairment Permanent Impairment (attached required worksheets and narrative)
Anticipate permanent impairment Needs referral to Level II physician for impairment rating (see 7b above)
11. PHYSICIAN’S SIGNATURE
Date of Report
Print Name License # Phone #
WC164 Rev 02/19
Page 1 of 2
Clear Form
Physician's Report of Workers' Compensation Injury
INSTRUCTIONS / DEFINITIONS
This form is required by the Workers’ Compensation Rules of Procedure Rule 16, 7 CCR 1101-3 to report all information
specific to this workers’ compensation injury.
Complete all applicable fields and attach your narrative report that further describes and supports your findings. Your narrative
report does not replace this form.
1. Report Type and Exam Date: Check “Initial” if this is the first visit related to this described injury. Check “Progress”
when a change in condition, diagnosis, or treatment occurs. Check “Closing” if the injured worker is at MMI, requires an
impairment rating, or is discharged from care. On “Exam Date,” include the date of the office visit, if applicable.
2. Case Information:
Date of Injury: Date of this injury.
Injured Worker: Name of the injured worker.
Social Security #: The injured worker’s social security number.
Date of Birth: The injured worker’s date of birth.
Insurer Claim #: The name of the insurance carrier or self-insured employer associated with the claim.
Employer Name: The name of the employer associated with the claim.
3. Initial Visit:
a. Describe how the accident or injury occurred in the injured worker’s words.
b. Check the applicable box regarding physician’s objective findings.
4. Current Work Status: Current work status as related by injured worker.
5. Work-Related Medical Diagnosis(es): State the injured worker’s work-related medical diagnosis(es).
6. Plan of Care:
a. Treatment Plan: Complete all applicable portions regarding treatment. Indicate frequency and duration.
Diagnostic tools/tests: EMG, MRI, CT-scan, etc.
Procedures: Any medical procedure including surgical procedures, castings, etc.
Therapy: Physical therapy, occupational therapy, home exercise, etc. Include plan specifications.
Medica
tions: Antibiotics, analgesics, anti-inflammatory drug
s, etc.
Supplies: Durable medical equipment, splints, braces, etc.
Other: Any treatment not covered above.
b. Work Status: Check the applicable work status box(es). List date(s) and hours as appropriate.
c. Limitations/Restrictions: Check the applicable box(es) regarding any medical or physical limitations or restrictions
including temporary or permanent restrictions.
7. Follow-up Care and Referrals:
a. Provid
e the date of the next scheduled appointment
b. If a referral was made to another provider, supply that provider’s name and phone number. Designate who is to
make the referral appointm
ent.
c. If the authorized physician refuses to provide medical treatment to an injured worker or discharges the injured
worker from medical care for nonmedical reasons when the injured worker requires medical treatment to cure an
d
relieve the effects of the work injury, then the physician must, within three (3) business days from the refusal or
discharge, provide written notice of the refusal or discharge by certified mail, return receipt requested, to the injured
worker and insurer. The notice must explain the reasons for the refusal or discharge and must offer to transfer the
injured worker’s medical records to any new authorized physician upon receipt of a signed authorization to do so
from the injured worker. For a template letter, flowchart, and information on reimbursement, refer to Desk Aid #15
on the Division website.
8. Maximum Medical Improvement (MMI): Check the applicable box(es). List additional information as appropriate. MMI
means a point in time when any impairment resulting from the injury has become stable and when no further treatment is
reasonably expected to improve the condition.
9. Maintenance Care after MMI: In some cases, MMI may be unknown because the injured worker has not returned for care.
10. Permanent Medical Impairment: Check the applicable box(es). If the injury will cause a permanent impairment, an
impairment rating performed by a Level II accredited physician is required. If an impairment rating is given, attach the
worksheets required by the Division and a report describing the extent of the injured worker’s impairment rating.
11. Physician Information: List the name, license number, and telephone number of the physician responsible for the report.
The physician responsible for the report must sign and date the report.
WC164 Rev 02/19
Page 2 of 2
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Physician's Report of Workers' Compensation Injury (Colorado DORA)

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Completed 27 January 2021

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