Form 14b - Physician'S Statement
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1South Carolina Workers’ Compensation Commission
Physician’s Statement
1333 Main Street, Suite 500 ● Post Office Box 1715
Columbia, South Carolina 29202-1715
(803) 737-5723
Claimant's Name:
_____________________________________
Employer’s Name:
_______________________________________
Physician’s Name:
_______________________________________
Insurance Carrier:
______________________________________
Practice/Clinic:
__________________________________________
SCWCC File No:
________________________________________
Preparer’s Name:
______________________________________
Phone:
_______________________________
The undersigned physician has been authorized by the Employer/Carrier to treat this Claimant for his or her injury by accident
pursuant to§§42-15-60, 42-1-172 or 42-11-10.
Date of Injury or Illness: _____________
Date of first office visit: _____________
Date of last visit: __________________
Diagnosis or nature of injury or illness: ________________________________________________________________________
Body part(s) injured: __________________________________Body part(s) affected: __________________________________
Date of Maximum Medical Improvement: ______________
Based on the AMA Guidelines, the claimant has sustained a _______% medical impairment to________________________
injured body part(s) and a ________% medical impairment to___________________________________________________
other affected body part(s).
The claimant is able to return to work without restriction.
The claimant is able to return to work with the following restrictions:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
The claimant is unable to return to work at his or her current employment.
Claimant possesses retained hardware casually related to this injury.
As of the date I last saw this patient, it is my professional medical opinion the claimant:
will not need future medical care related to his or her work related injury or illness based on a reasonable degree of
medical certainty (more likely than not).
will need future medical care and treatment related to his or her work related injury or illness based on a reasonable
degree of medical certainty (more likely than not) and that medical care and treatment including medication is as follows:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________________________
________________________
Treating Physician
Date
9/13
Physician’s Statement
14B
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