Form Dfc-F5-Dwc-25 - Florida Workers' Compensation Uniform Medical Treatment/ Status Reporting Form

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Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 1
BEFORE COMPLETING THIS FORM, PLEASE CAREFULLY REVIEW THE INSTRUCTIONS BEGINNING ON PAGE 3
NOTE: Health care providers shall legibly and accurately complete all sections of this form, limiting their responses to their area of expertise.
FOR INSURER USE ONLY
1.
Insurer Name:
2.
Visit/Review Date:
3.
Injured Employee (Patient) Name:
4.
Date of Birth:
5.
Social Security #:
6. Date of Accident:
7. Employer Name
Initial visit with this physician?
8.
a) NO
b) YES
SECTION I
CLINICAL ASSESSMENT / DETERMINATIONS
9.
No change in Items 9 - 13d since last reported visit. If checked,
GO TO SECTION II.
10.
Injury/ Illness for which treatment is sought is:
NOT WORK RELATED
a)
b) WORK RELATED
c) UNDETERMINED as of this date
11. Has the patient been determined to have Objective Relevant Medical Findings?
Pain or abnormal anatomical findings, in
the absence of objective relevant medical findings, shall not be an indicator of injury and/or illness and are not compensable.
a) NO
b) YES
c) UNDETERMINED as of this date
If YES or UNDETERMINED, explain:
Diagnosis(es):
12.
Major Contributing Cause: When there is more than one contributing cause, the reported work-related injury must
13.
contribute more than 50% to the present condition and be based on the findings in Item 11.
a) Is there a pre-existing condition contributing to the current medical disorder?
a
) NO
a
) YES
a
) UNDETERMINED as of this date
1
2
3
Do the objective relevant medical findings identified in Item 11 represent an exacerbation (temporary worsening)
b)
or aggravation (progression) of a pre-existing condition?
b
) NO
b
) exacerbation
b
) aggravation
b
) UNDETERMINED as of this date
1
2
3
4
Are there other relevant co-morbidities that will need to be considered in evaluating or managing this patient?
c)
c
) NO
c
) YES
1
2
Given your responses to the Items above, is the injury/illness in question the major contributing cause for:
d)
d
) NO
d
) YES
the reported medical condition?
1
2
d
) NO
d
) YES
the treatment recommended (management/treatment plan)?
3
4
d
) NO
d
) YES
the functional limitations and restrictions determined?
5
6
SECTION II
PATIENT CLASSIFICATION LEVEL
14. LEVEL I - Key issue: specific, well-defined medical condition, with clear correlation between objective relevant
physical findings and patients' subjective complaints. Treatment correlates to the specific findings.
Key issue: regional or generalized deconditioning (i.e. deficits in strength, flexibility, endurance, and
15. LEVEL II -
motor control. Treatment: physical reconditioning and functional restoration.
16. LEVEL III -Key issue: poor correlation between patient's complaints and objective, relevant physical findings, indicating
both somatic and non-somatic clinical factors. Treatment: interdisciplinary rehabilitation and management.
17. LEVEL UNDETERMINED AS OF THIS DATE.
SECTION III
MANAGEMENT / TREATMENT PLAN
If checked,
18. No clinical services indicated at this time.
GO TO SECTION IV
No change in Items 20a - 20g since last report submitted.
If checked,
19.
GO TO SECTION IV
The following proposed, subsequent clinical service(s) is/are deemed medically necessary.
20.
*** THIS IS A PROVIDER'S WRITTEN REQUEST FOR INSURER AUTHORIZATION OF TREATMENT OR SERVICES. ***
Consultation with or referral to a specialist.
Identify principal physician:
a)
Identify specialty & provide rationale:
)
a
)
CONSULT ONLY
a
REFERRAL & CO-MANAGE
a
)
TRANSFER CARE
1
2
3
Diagnostic Testing: (Specify)
b)
c)
Physical Medicine.
Check appropriate box and indicate specificity of services, frequency and duration below:
)
c
Physical/Occupational therapy, Chiropractic, Osteopathic or comparable physical rehabilitation.
1
)
c
Physical Reconditioning (Level II Patient Classification)
2
)
c
Interdisciplinary Rehabilitation Program (Level III Patient Classification)
3
Specific instruction(s):
d)
Pharmaceutical(s) (specify):
DME or Medical Supplies:
e)
Surgical Intervention - specify procedure(s):
f)
)
f
In-Office:
1
)
f
Surgical Facility:
2
)
f
Injectable(s) (e.g. pain management):
3
Attendant Care:
g)
Form DFS-F5-DWC-25 (revised 2/14/2006)
Page 1 of 2

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