Form Erd-985 - Application Form For Certification By The Subsequent Injury Fund - Montana Department Of Labor And Industry Page 6

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Has Maximum Healing Been Reached?
Yes ____ No ____
If No, When Do You Anticipate It Will Be Reached?_____________________________________________________________
Is There Permanent Impairment As Defined Above?
Yes _____ No _____
(A rating need not be assigned to meet our criteria)
If No Impairment, Please Explain: _________________________________________________________________________
_______________________________________________________________________________________________________
Are There Permanent Restrictions Or Limitations?
Yes _____ No _____
Please Describe In Detail: ________________________________________________________________________________
______________________________________________________________________________________________________
Is Condition Stable?
Yes _____
No _____
If No, Explain: ___________________________________________________________________________________
____________________________________________________________________________________
What Medical Treatment, If Any, Is Recommended To Treat This Condition? _______________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Other Comments/Concerns: _______________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PHYSICIAN NAME: (PLEASE PRINT) ____________________________________________________
ADDRESS: _______________________________________________________
PHONE: _________________________________________________________
_______________________________________________________________________________________
SIGNATURE OF PHYSICIAN
DATE
ERD – 987 (REV 07/05/2000)

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