Form Medco-14 - August 2015 Physicians Report Of Work Ability Page 2
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4Instructions for Completing the
Physician’s Report of Work Ability
Instructions continued
4A: Disability period information section: It is critical that if you answered No to 3B or made changes to dates in 3B
this section is fully completed: Please furnish the narrative description of the diagnosis(es), site/location and International
Classification of Diseases code for only allowed conditions being treated. You must indicate by checking the appropriate box
whether the allowed condition is preventing the injured worker from returning to the job held on the date of injury.
4B: In this area you should list all other relevant conditions that impact treatment of the allowed conditions in the claim.
Clinical findings section: Provide medical rationale for the delay in the injured worker’s recovery and the barriers to return
to work.
Maximum medical improvement (MMI) section: Provide the MMI date or explain why the injured worker has not reached
MMI. Provide the proposed treatment plan, including estimated duration.
Vocational rehabilitation section: If the injured worker is not a candidate for vocational rehabilitation, explain and recom-
mend actions to help the injured worker return to employment.
Treating physician’s signature section: Sign and date this form. Your signature indicates you have answered the questions
as truthfully and completely as possible.
For more information or assistance
Please contact your local BWC customer service office, or call 1-800-644-6292. You can obtain BWC forms at
gov, at all BWC customer service offices, or by calling 1-800-644-6292 and listening to the options to reach a BWC customer
service representative.
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
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