Physician'S Form Instructions/definitions printable pdf download

PHYSICIAN’S FORM

INSTRUCTIONS/DEFINITIONS

The use of this form is required by the Delaware Workers’ Compensation Statute, 19 Del.C. §2322E, to report all

information specific to this workers’ compensation injury. In the event the physician electronically generates this

information, the physician’s submission is required to contain all information specific to this workers’

compensation injury as set forth in the Physician’s Form.

Complete all applicable fields. Your office notes and records do not replace this form.

Report Type: Check “Initial” if this is the first visit related to this described injury. Check “Progress” when there has

been any material change in the injured employee's physical capability which impacts the employee's return to work

status. Check “Closing” if: injured worker is discharged from care.

Case Information:

 Injured Worker’s Name: Name of the injured worker.

 Date of Birth: The injured worker’s date of birth.

 Date of Injury: Date of this injury.

 Exam Date: Date of office visit if applicable.

 Physician’s Phone/Fax: The telephone and fax numbers of the physician completing this form.

 Employer Name: The name of the employer associated with the claim.

 Employer Phone/Fax: The telephone and fax numbers of the employer.

 Insurer Name: The name of the insurance carrier associated with the claim, if known.

 Insurer Claim #: The claim number assigned by the insurance carrier or self-insured employer, if known.

 Insurer Phone/Fax: The telephone and fax numbers of the insurance carrier associated with the claim, if known.

Initial Visit: Relate in injured worker’s words description of accident/injury.

Work Related Medical Diagnosis(es): State the injured worker’s work related medical diagnosis(es).

Treatment Plan: Complete all applicable portions regarding treatment. Indicate frequency and duration.

 Diagnostic tools/tests: EMG, MRI, CT-scan, etc.

 Procedures: Any medical procedure including surgical procedures, castings, etc.

 Therapy: Physical therapy, occupational therapy, home exercise, etc., including plan specifications.

 Medications: Antibiotics, analgesics, anti-inflammatory drugs, etc.

 Other: Any treatment not covered above.

Hours Per Day Patient Can Work: Circle the number of hours applicable to this patient.

D.O.T. Classification of Work: Circle the classification of work applicable to this patient.

Work Postures/Positional Tolerances: Comment as appropriate in the space provided regarding the patient's

abilities/limitations for the postures/positions listed.

Comments: To be used to explain/clarify any information required by this form.

10.

Restrictions: Check applicable category.

11.

Return to Work: Provide regular duty/modified duty start date.

12.

Reevaluation Date: Provide date of next evaluation.

13.

Physician Information: Type or print the name of the physician and circle "yes" or "no" as to whether the physician is

a Certified Provider. The health care provider most responsible for the treatment of the employee's work-related injury

must sign and date the report.

The health care provider most responsible for the treatment of the employee's work-related injury shall complete

and submit, as expeditiously as possible and not later than 10 days after the date of first evaluation or treatment, a

report of employee condition and limitations, on a form adopted for that purpose pursuant to this section, and

shall expeditiously provide copies of the report of employee condition and limitations to the employee, the

employer and the employer's insurance carrier, if applicable, as required by 19 Del. C. §2322E(b).

Physician'S Form Instructions/definitions

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