Form Medco-14 - August 2015 Physicians Report Of Work Ability Page 4
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2
3
4Injured worker name
Claim number
Date of injury
Disability information
(If 3B above is “NO” or dates updated - all 4A fields, including site/location if applicable must be completed)
(Updates Yes
No
)
Complete the chart below and furnish the narrative description of the diagnosis(es), site/location, if applicable, and International
Classification of Diseases (ICD) code(s) for the condition(s) being treated due to the work-related injury/disease. Please indicate if
the condition is preventing the injured worker from returning to job duties he/she held on the date of injury.
Site/location
ICD
Is the condition preventing full duty release to
Narrative description of the work-related allowed condition
if applicable
code
the job injured worker held on the date of injury?
Yes
No
4A
Yes
No
Yes
No
Yes
No
Yes
No
List all other relevant conditions that impact treatment of the conditions listed above (e.g., co-morbidities or not yet allowed conditions).
4B
Clinical findings: You can reference office notes in lieu of writing clinical findings below.
(Updates Yes
No
)
The injured worker is progressing:
As expected
Better than expected
Slower than expected
Provide your clinical and objective findings supporting your medical opinion outlined on this form. List barriers to return to work and
reason, for the injured worker’s delay in recovery.
5
Maximum medical improvement (MMI)
(Updates Yes
No
)
MMI is a treatment plateau (static or well-stabilized) at which no fundamental functional or physiological change can be expected within
reasonable medical probability, in spite of continuing medical or rehabilitative procedures. Has the work-related injury(s) or occupational
disease reached MMI based on the definition above? Yes
No
If yes, give MMI date: _______________. If no, please provide the proposed treatment plan, including estimated duration of each treat-
ment (attach additional sheet if necessary).
6
Note: An injured worker may need supportive treatment to maintain his or her level of function after reaching MMI. Thus, periodic medical treatment
may still be requested and provided.
Vocational rehabilitation
(Updates Yes
No
)
Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning to
work or in retaining employment. This program can be tailored around an injured worker’s restrictions and may provide job seeking skills or
necessary retraining. Is the injured worker a candidate for vocational rehabilitation services focusing on return to work?
Yes
No
If no, please explain why and provide your recommendations to help the injured worker return to employment.
7
Treating physician signature - mandatory
I certify the information on this form is correct to the best of my knowledge. I am aware that any person who knowingly makes a false
statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC, or who knowingly
accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may be punished, under appropriate
criminal provisions, by a fine or imprisonment or both.
Treating physician’s name (please print legibly)
Address, city, state, nine-digit ZIP code
8
Treating physician’s signature
BWC provider (Peach) number
Date
Telephone number
Fax number
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
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