Florida Workers Compensation Uniform Medical Treatment-Status Report Form {DWC-25}

Florida Workers Compensation Uniform Medical Treatment/Status Reporting Form BEFORE COMPLETING THIS FORM, PLEASE CAREFULLY REVI EW THE INSTRUCTIONS BEGINNING ON PAGE 3. NOTE: Physicians shall legibly and accurately complete all sections of this form, limiting their responses to their area of expertise. Information preceded by an asterisk () is to be completed only for the initial v isit. FOR INSURER USE ONLY 1. Insurer Name: 2. Visit / 30-Calendar Day Review Date: 3. Patients Name: 4. Patients Social Security No.: 5. Date of Birth: 6. Patients Occupation 7. Name of Employer 8. Date of Reported Injury: The fact that a patient has been referred to a physician by an insurer for a reported work injury does not mean the identifiedclinical dysfu nction is causally related to the reported work incident. Further, the fact that a physician has determined the initial injury to be work related does not necessarily mean that additional patient complaints or secondary symptoms are work related. Section I Clinical Assessment 9. a) Condition for which treatment is sought is not related to the work injury. b) No Change in Clinical Assessment (Items 10 - 13 since l) ast report submitted. (Go to Section II) 10. Objective Relevant Medical Findings: Pain or abnormal anatomical findings, ine abse th nce of objective relevant medical findings shall not be an indicator of injury and/or illness and are nompt coensable. Therefore, the phicianys shall apply requiremenpts ursuant to ss.440.09(1) and 440.13(16)(a) F.S. to dates of accident on or after 10/1/2003. ee i(S nstructions for dates of accident pritoor 10/1/2003) Has the patient been determined to have objective relevant medical findina)gs ? No b) Yes c) If yes, specify below. _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 11. Specify diagnosis related to findings identified in 10c: _____________________________________________________________ 12. Major Contributing Cause : When there is more than one contributing cauthe se, reported work related injury must contribute more than 50% to the present condition and be based on the find ining 10sc. The Physician shall apply language found in 40ss. .049(1) and 440.13(16)(a), F.S. to dates of accident on or after 10/1/2003. (See instructions for dates of accident prior to 10/1/2003.) a) Have you determined that there is a pre-existing condition contributing to the current medical disordera1) ? Yes a2) No b) Do the objective relevant medical findings identified in Item 10c represent anacerbation (tem ex porary worsening) or aggravation (progression) of a pre-existing condition? b 1) Yes b2) No If yes, check: b3 ) exacerbation or b4) aggravation c) Are there other relevant co-morbidities that will need b toe considered in evaluating or managing this case?c1) Yes c 2) No Note: if either 12 a1) - c1) are checked, specific details must be documented in youmr edical records. d) Given your responses to Items 10 12a-c, above, is the injury in question the major contributing cause for: the reported medical condition? d1 ) Yes d 2) No the treatment recommended (management/treatment plan)? d3 ) Yes d 4) No the functional limitations and restrictions determined? d5 ) Yes d 6) No 13. Patient Classification: For this visit, the physician must identify the apprate leopri vel that accurately represents the patients status based upon objective relevant medical findings. Indicate the most appropriate level listed below. (See instructions) a) Level I: Well defined, work-related medical conditioasson ciated with specific physiologic dysfunction(s); little or no discdanceor between physical findings and the medical complaint. b) Level II: Defined by the presence of systemic abnorms, i.e., dealitieficits in strength, flexibility, endurance, motor control; may or may not have well-defined specific physiologic dysfunction(s). c) Level III: Defined by the presence of significant, associated psychological or vocational issues; have systemic defiesecintts pr (see Level II); may or may not have specific physiologic dysfunction(s). d) Patient status undetermined at this time for the following reason(s) _______________________________________________ __________________________________________________________________________________________________ Section II Management / Treatment Plan 14. No Change in Management/Treatment Plan (Items 15 - 16) since last report submitted. (Go to Section III) 15. Based upon the preceding Clinical Assessment (Items 10 13)appl, ying provisions under ss.440.09 and 440.13, F.S. and other applicable statutory sections of Chapter 440, F.S., the following treatment(s) is/are deemed necessary and proposed for auzatthiorion by the insurer: a) No treatment indicated at this time. b) Consultation with/referral to Specialist/Practitioner: Physician completing this form requests to continue to serve as thincie prpal treating physician for the reported work related injury, buqut reests a consultation with/referral to a (specify specialty anprovid de rationale): ____________________________________________________________________________________________________ c) Transfer of care to a Specialist: The ysicianPh completing this form will not remain the principal treating physician for th e reported work related injury and hereby recommends authoon rizatifor transfer of care to a (specify specialty and provide ratnaleio): _____________________________________________________________________________________________________________ DFS-F5-DWC - 25 (03/2004) 1 <<<<<<<<<********>>>>>>>>>>>>> 2Section II Management / Treatment Plan d) Diagnostic Testing (specify): ____________________________________________________________________________ _ e) Physical Medicine. Check appropriabote x and indicate specificity of services, frequency and duration in the section below. 1. Physical Therapy, Chiropractic, Oteopathisc or comparable treatment 2. Physical Reconditioning (Level II Patient Classification) 3. Interdisciplinary Rehabilitation Program, Commission onAccreditation of Rehabilitation Facilities (CARF)/Joint Commission on Accreditation of Healthcare Organizations (JCAHO), e.g. work hardening, chronic pain (Level III Pt. Classin) ficat i o Please specify details (timeframes and other parameters): __________________________________________________________