Medical Report Transmittal Form {14-0141}

Medical Report Transmittal Form IAC 876-3.1(2)(17A) Medical data supporting the action taken shall be (provided) when temporary total disability or temporary partial disability exceeds 13 weeks or when the employee sustains a permanent disability. Please complete and attach this form to the front of medical data orreports when they are submitted to the Iowa Division of WorkersCompensation. Jurisdiction Claim Number: Claim Administrator Claim Number: Claim Administrator Name: Employee ID (number): Date of Injury: Employee Last Name: Employee First Name: Current Return to Work Date: (if applicable) Date of Maximum Medical Improvement: (if applicable) Permanent Impairment Body Part Code: (if applicable) Permanent Impairment Percentage: (if applicable) Doctors Name: Comments: Please Mail or Fax to: Division of Workers Compensation 1000 East Grand Avenue Des Moines, Iowa 50319-0209 Fax Number: (515) 281-650114-0141 3/00