Form Medco-14 - August 2015 Physicians Report Of Work Ability

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Instructions for Completing the
Physician’s Report of Work Ability
This form provides important information about the injured worker’s ability to work.
• The treating physician must submit this form each time he/she sees the injured worker unless the injured worker has
been awarded permanent and total disability, has returned to work without restrictions within seven days of the injury,
or is being treated after the treating physician has released him/her to his/her former position without restrictions.
• Please complete this form and provide a copy to the injured worker during his/her office visit. Fax a copy to the appro-
priate managed care organization (MCO) or to the injured worker’s employer if self-insured.
• This form or an equivalent physician-generated document may support a request for temporary total compensation.
The equivalent document must contain, at a minimum, the data elements required on this form. If you have submit-
ted previously equivalent data elements that remain the same, indicate the name of the report that reflects the injured
worker’s current condition, e.g., May 15, 2015, office note.
• You may attach additional medical documentation such as diagnostic test results and a treatment plan to this form.
• Failure to provide complete detailed information may delay or suspend compensation payments to the injured worker.
Instructions
MEDCO-14 submission section: You must select only one of the three choices by selecting the appropriate box. If you
previously completed a MEDCO-14 and there are changes, you must indicate the changes in the appropriate section on the
form, and select the yes box in that section. For all other sections, you would make no entry, and select the no box.
Employment/occupation section: Please indicate if you have reviewed a description of the injured worker’s job held on the
date of the injury. Please indicate all sources providing you a description of the injured worker’s job. If you do not have a copy
of the injured worker’s job description, BWC or the MCO can help secure one.
Work status/Injured worker’s capabilities section: Please complete this section as accurately and thoroughly as possible,
as BWC will use this information to understand the injured worker’s work status and help facilitate his/her appropriate and
safe return to work either to his/her job held on the date of injury or an alternative job if he/she cannot return to the job held
on the date of injury.
3A: Please indicate if the injured worker has any physical or health restrictions related only to the allowed conditions in the
claim. If there are restrictions, please indicate if the restrictions are permanent or temporary. If there are no related restrictions
you should check the release to work box. The date of the exam will be the release to work date.
3B: If there are restrictions related only to the allowed conditions in the claim, indicate whether or not the injured worker
can return to the full duties of his/her job held on the date of injury. If you determine the injured worker cannot return to the
full duties of his/her job held on the date of the injury, you must included the date for which you indicate the injured worker
could not fully perform the duties of his/her job held on the date of the injury. You must also indicate an estimated date when
you believe the injured worker should be able to fully perform the duties of the job held on the date of injury. It is imperative
that you follow all 3B instructions. This will facilitate appropriate processing of the injured worker’s claim. Updates
to dates in 3B requires 4A to be completed.
3C: Although an injured worker may not be able to fully return to the job held on the date of injury, understanding the injured
worker’s capabilities will assist in identifying appropriate and safe work that an injured worker may be able to perform. If an
injured worker may return to available and appropriate work with restrictions accommodated, please indicate the possible
return to work date. Further, to facilitate BWC’s efforts to safely return an injured worker to appropriate work, indicate which
of the activities listed in this section, the injured worker can perform. The following definitions apply to the section on Lifting/
carrying, Pushing/pulling and Activity with the percentages reflected as they relate to an eight-hour workday:
• Never – 0 percent;
• Occasionally – 1 percent to 33 percent, four to six repetitions per hour;
• Frequently – 34 percent to 66 percent, six to 12 repetitions per hour;
• Continuously – 67 percent to 100 percent, greater than 12 repetitions per hour.
Please note that if the “yes” box is checked in response to the question of whether the injured worker has functional restrictions
based only on allowed psychological conditions the MEDCO-16 should be referenced as needed.
We encourage you, in the space provided, to provide any additional information you believe would benefit the injured worker’s
safety and care relative to any return to work considerations.
Instructions continued on page two
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14

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