Form 75 Wca-1 - New Hampshire Workers' Compensation Medical Form 1994
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1NEW HAMPSHIRE WORKERS’ COMPENSATION MEDICAL FORM
This form must be completed at each health professional visit (MD, DO, DC or DDS) and must be filed with the workers’
compensation insurance carrier within 10 days of the treatment (first aid excluded). Failure to comply and complete this form shall result in the
provider not being reimbursed for services rendered and may result in a civil penalty of up to $2,500.
In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary alternative/transitional work
opportunities to all employees temporarily disabled by a work related injury or illness.
Employee____________________________________________
Employer_______________________________________________
SS#_________________________________________________
Work telephone #________________________________________
Occupation___________________________________________
Employer contact________________________________________
Date last worked_______________________________________
Employer address________________________________________
W.C. insurer__________________________________________
________________________________________
HEALTH PROFESSIONAL TO COMPLETE
Initial visit
Follow-up visit
Date of Injury__________________________ Time______________
Worker’s statement of the incident__________________________________________________________________________
Worker’s complaints_____________________________________________________________________________________
Diagnosis/Prognosis______________________________________________________________________________________
Treatment plan__________________________________________________________________________________________
______________________________________________________________________________________________________
In your opinion is this injury and disability as a result of injury described above?
Yes
No
Unclear
EMPLOYEE WORK CAPABILITY
Continue Working
Can return to work:
Yes
Date______________________
No
Full Duty
With Modification. If so, for what duration?_______________________________________
Employee Can
No Restrictions
Frequently
Occasionally
Unable to
Employee can lift/carry maximally ________ lbs.
Employee can lift/carry frequently _________lbs.
bend
kneel
Employee can work a maximum of #_____
squat
hours/day, #_____days/wk.
climb
What special accommodations are required?_______
stand
___________________________________________
walk
sit
Other______________________________________
reach
Has employee reached maximum medical
drive
improvement?
do fine motor
Yes
No
Has injury caused permanent impairment?
Wrist
Elbow
Shoulder
Ankle
No
Yes
No
Undetermined
Right
repetitive
motions
Left
ALL MEDICAL NOTES MUST BE ATTACHED TO BILL
I certify that the narrative descriptions of the principal and secondary diagnosis and the major procedures performed are accurate
and complete to the best of my knowledge.
___________________________________
_________________________________
__________________________
Provider’s signature
Provider’s Printed name
Provider’s telephone #
____________________________________________
__________________________________________
Federal ID#
Date of Visit
MEDICAL AUTHORIZATION: The act of the worker in applying for workers’ compensation benefits constitutes authorization to any physician,
hospital, chiropractor, or other medical vendor to supply all relevant medical information regarding the worker’s occupational injury or illness to the
insurer, the worker’s employer, the worker’s representative, and the department. Medical information relevant to a claim includes a past history of
complaints of, or treatment of, a condition similar to that presented in the claim. [281-A:23 V(a)]
75 WCA-1 (06/94)
White – Insurer/Managed Care
Yellow – Provider
Pink – Employee/Employer
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