Self-Insured Employer Injured Worker Screening {BWC-3909}

Statewide Disability Evaluation System Instructions · The employer should sign and date the form. · Incomplete and/or improper completion of this form will result in delay in processing. · Submittolocalcustomerserviceoffice:Attn:SDESnurse. · Please complete this form for the Statewide Disability Evaluation System. This system is for scheduling examinations of injured workers who have received 90 consecutive days of temporary total disability compensation and monitoring for re-examination as necessary. We use this form to identify the injured worker we will examine. 1.Injuredworkername(last,first,middleinitial) 4.Address 5. City 9. Telephone number ( ) 6. County 10. Sex Male Female 11. Date of birth 7. State 8. Nine-digit ZIP code 12. Date of injury Self-Insured Employer/Injured Worker Screening Injured Worker Information 2. Social Security number 3. Claim number 13. Employer name 1 5.Address 17. City 20. Employer contact Employer Information 14. Risk number 16. Telephone number ( ) 8. Nine-digit ZIP code 18. State 21. Title 22. Representative 2 4.Address 28. Contact Injured Worker Representative 25. City 23. Telephone number ( ) 26. State 27. Nine-digit ZIP code 29. Representative 3 1.Address 35. Contact Employer Representative 32. City 30. Telephone number ( ) 33. State 34. Nine-digit ZIP code 36.Doestheemployerwishtowaivethe90-dayexamforthisinjuredworker?YesNoIfyes,forthisexamonlyorindefinitely Reason BWC-3909 (Rev. 2/25/1999) MEDCO-8 Pg. 1 American LegalNet, Inc. www.FormsWorkFlow.com NOtE Do not complete remainder of form if you waive the examination. Please sign, date and complete Waiver. 37. Physician of record 39.Address 41. City 44. Consulting physician 46.Address 48. City Physician's Information 38. Specialty OBWC Provider number 40. Telephone number ( ) 43. Nine-digit ZIP code OBWC Provider number 47. Telephone number ( ) 50. Nine-digit ZIP code 42. State 45. Specialty 49. State 51.Allowedcondition (ICD-9) Codes as available 52. Disallowed or unrelated conditions 53. Length of time on job at date of injury 54. Total time worked for employer 55. Job title at date of injury ________ years ________months ________wks ________ years ________months ________weeks 56. Employer job task summary (may attach job description if available) American LegalNet, Inc. www.FormsWorkFlow.com 57. What are the physical requirements of the job? 58. Is there a job for the injured worker to return to? Pleasespecify: Yes No 59.Aretheremodifiedworkoptionsavailabletotheinjuredworker?YesNo 60. Description of accident (or copy of C-50) 61. Is the injured worker hospitalized? Yes No 62.Arethereanypre-existingconditions(co-morbidityfactors)whichcouldprolong therecoveryperiod?YesNoIfyes,explain: 63. Is there any additional information relevant to this claim? BWC-3909 (Rev. 2/25/1999) MEDCO-8 Pg. 2 American LegalNet, Inc. www.FormsWorkFlow.com 64. Expected length of temporary total disability compensation for __________________weeks 65. Injured worker has received temporary total disability compensation for ________________________ days 66. Please include copies in duplicateofthemedicalinformation/reportsintheclaimfile,forexample:C-1-A; C-50;C-84;resultsofdiagnosticstudies(X-rays,lab,nuclearmedicine,myelogram,MRI,etc.);operative report;hospitaldischargesummary;historyandphysical;admissionreport;physiciannotes/reports/summaries;physicaltherapynotes/treatmentplanetc. 67. Areyouawareofanyadditionalordereddiagnosticstudiesorscheduledhospitalizations,whichtheclaim filedoesnotcontain? Yes No Specify OBWC please return examination report to: Completed by Date American LegalNet, Inc. www.FormsWorkFlow.com