FORM 4
COURT OF EXISTING CLAIMS
This space for Court Use only
1915 NORTH STILES, STE 127
SEND COPIES TO
OKLAHOMA CITY, OK 73105-4918
1—Injured Worker
1—Employer
1—Employer’s Insurer
In re claim of:
Full Name of Injured Employee (Claimant)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX______________________
Name of Employer (Respondent)
WCC FILE NO.
(Must be filled out)
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own
Risk Group, Uninsured
TREATING PHYSICIAN’S REPORT AND NOTICE OF TREATMENT
)
(Please type or print
1. HISTORY OF ACCIDENT: Date and Time of Accident
Occupation or job of employee
(Please type or print)
State, in the employee’s own words, how the accident occurred.
Were the employee’s injuries causally connected to the above described accident?
2. MEDICAL HISTORY
Age
Date of birth
State the objective complaints of the employee.
State whether previous sickness or injury contributed to the employee’s present condition.
Was the employee hospitalized?
Other significant medical history of the employee.
Describe the medical treatment rendered to date.
List all other treating or consulting physicians.
Were medical records reviewed?
3. CLINICAL EVALUATION: Describe your examination and all diagnostic tests performed.
State your findings and diagnoses.
Describe the medical treatment you recommend for the future.
4. EVALUATION OF TEMPORARY TOTAL DISABILITY: Date of employee’s first treatment by you.
State the date you released the employee as able to return to work.
Has the employee been totally unable to return to work for any period?
Employee was temporarily totally disabled from:
Is the employee’s inability to work the result of the above described accident?
I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct
and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Signed this ____________ day of _________________, ________
Type or Print Name of Treating Physician
Employee
Employer
Insurance Carrier
Address (Number and Street)
Signature of Treating Physician
City
State
Zip Code
Address
City
State
Zip Code
Rev. 06/24/2015