Form Erd-985 - Application Form For Certification By The Subsequent Injury Fund - Montana Department Of Labor And Industry Page 5
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6STATE OF MONTANA
DATE RECEIVED
DEPARTMENT OF LABOR AND INDUSTRY
SUBSEQUENT INJURY FUND
EMPLOYMENT RELATIONS DIVISION
P.O. BOX 8011
HELENA, MT
59604-8011
444-7737
SUBSEQUENT INJURY FUND MEDICAL EVIDENCE OF IMPAIRMENT FORM
PART A (To be completed by applicant)
NAME OF APPLICANT:_________________________________
SOC. SEC. # :___________________________________
ADDRESS:_____________________________________________
PHONE : _____________________________________
_____________________________________________
BIRTH DATE: __________________________________
PART OF BODY __________________________________________________________________________________________
SIGNING THIS MEDICAL EVIDENCE OF IMPAIRMENT FORM IS MY AUTHORIZATION FOR RELEASE OF
HEALTHCARE INFORMATION TO THE SUBSEQUENT INJURY FUND, EMPLOYMENT RELATIONS DIVISION.
_______________________________________________________________________
________________________
SIGNATURE OF APPLICANT
DATE
PART B (To be completed by a medical doctor or chiropractor)
INSTRUCTIONS
The above named individual has applied for certification by the Subsequent Injury Fund as a person with a disability. To help us
determine if the applicant meets the criterion, please complete this questionnaire and return it to the Subsequent Injury Fund.
Also, attach any medical records that substantiate the impairing medical condition of the applicant. If you have any questions,
please contact the Employment Relations Division, Subsequent Injury Fund at (406) 444-7737.
Section 39-71-901, MCA defines a person with a disability as a person who has a medically certifiable permanent impairment that
is a substantial obstacle to obtaining employment or to obtaining reemployment if the employee should become unemployed,
considering such factors as the person’s age, education, training, experience, and employment rejection.
Permanent restrictions placed on workers’ return to employment or reemployment are compared to the above factors to determine
whether there is a substantial obstacle as a result of the permanent impairment.
To meet the medical requirement for certification, the applicant must substantiate that he/she has “a medically certifiable
permanent impairment.” The American Medical Association (Guides to Evaluation of Permanent Impairment) defines impairment
“as the loss of, loss of use of, or derangement of any body part, system or function. A permanent impairment is an impairment that
has become static or well stabilized with or without medical treatment, or that is not likely to remit despite medical treatment of
the impairing condition.”
QUESTIONNAIRE
Are You Or Have You Been The Applicant's Treating Physician
Yes _____ No _____
Date Of Most Recent Examination Of Applicant: ________________________
Nature Or Diagnosis Of Injury Or Condition: _________________________________________________________________
_________________________________________________________________________________________________________
ERD – 987 (REV 07/05/2000)
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