Dwc Form Pr-2 - Physician'S Progress Report
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State of California
Additional pages attached
Division of Workers’ Compensation
PRIMARY TREATING PHYSICIAN’S PROGRESS REPORT (PR-2)
Check the boxes which indicate why you are submitting a report at this time. If the patient is “Permanent and Stationary”
(i.e., has reached maximum medical improvement), do not use this form. You may use DWC Forms PR-3 or PR-4.
Periodic Report
(required 45 days after last report)
Change in treatment plan
Released from care
Change in work status
Need for referral or consultation
Response to request for information
Change in patient’s condition
Need for surgery or hospitalization
Request for authorization
Other:
Patient:
Last _________________________________First ________________________M.I._______________Sex _______
Address__________________________________City________________________ State ______Zip____________
Date of Injury________________ Date of Birth_____________________
Occupation
SS # _____-_____-________ Phone (___)______________________
Claims Administrator:
Name_______________________________________________ Claim
Number_______________________________
Address_____________________________________City_____________________ State______Zip_____________
Phone (
)
________________________________ FAX (
)
_____________________________________
Employer name:
Employer Phone (
)
The information below must be provided. You may use this form or you may substitute or append a
narrative report.
Subjective complaints:
Objective findings: (Include significant physical examination, laboratory, imaging, or other diagnostic findings.)
Diagnoses:
1.
ICD-9 ______________________
2.
ICD-9 ______________________
3.
ICD-9 ______________________
Treatment Plan: (Include treatment rendered to date. List methods, frequency and duration of planned treatment(s).
Specify consultation/referral, surgery, and hospitalization. Identify each physician and non-physician provider. Specify
type, frequency and duration of physical medicine services (e.g., physical therapy, manipulation, acupuncture). Use of
CPT codes is encouraged. Have there been any changes in treatment plan? If so, why?
DWC Form PR-2
1
(Rev. 06-05)
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