Form Letter To Health Care Provider
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1
2NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION
FORM LETTER TO HEALTH CARE PROVIDER
INSTRUCTIONS:
1) Please fill out and promptly return the requested information as it is necessary to further evaluate the Worker’s legal
claims. Base your answers on a reasonable medical probability. Please answer all questions which you believe to be pertinent
to the Worker’s claim. Please give one copy of the completed form to the Worker. The maximum allowable fee that may be
charged for completion of this form is set forth in the health care provider fee schedule. The bill for completion of this form
should be sent to the claims administrator.
2) Return the completed form letter to:
Name:
_____________________________________________________
Address: _________________________________________________ _____
_______________________________________________________
TO:
Health Care Provider
Name:
_______________________________________________
Address:
_______________________________________________
_______________________________________________
RE:
Worker:
Name:_________________________________________WCA#_____________________
Last, First
DOB:_____________________________SSN (last four digits): XXX-XX-________
1. What was the date that the Worker was first seen/treated?________________________________________
2. What was the date that the Worker was last seen/treated? ________________________________________
3. What is the diagnosis of the condition(s) for which you have treated the Worker? _____________________
______________________________________________________________________________________
______________________________________________________________________________________
4. In your opinion, are the conditions or complaints for which you have treated the Worker causally-related to
an on-the-job injury or exposure? YES____ NO____ Date of Injury/Occurrence: ______________
5. Indicate the period of time, if any, the Worker has been unable to work? ____________________________
6. Is the Worker able to return to work? YES____ NO____
If no, when do you anticipate return to work? _________________________________________________
7. Has the Worker reached maximum medical improvement (MMI)?
____
YES
Date of MMI:________________________________________________
____
NO
Anticipated date of MMI:_______________________________________
8. If the Worker has reached MMI and you have already assessed Worker’s impairment, please indicate your
opinion as to the percentage of the Worker’s anatomical or functional abnormality as of the date of MMI:
a. Percentage of impairment, if any_____________________________________________________
b. Whole body or body part:___________________________________________________________
c. Indicate which edition of AMA Guides used: ___________________________________________
d. AMA page numbers:______________________________________________________________
Revised 10/1/15
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