Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report printable pdf download

Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report

STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

This form is required to be used for ratings prepared pursuant to the 1997 Permanent Disability Rating Schedule. It is

designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the

claims administrator. It should be completed if the patient has residual effects from the injury or may require future

medical care. In such cases, it should be completed once the patient’s condition becomes permanent and stationary.

This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to

report a medical-legal evaluation.

Patient:

Last Name_____________________ Middle Initial____First Name____________Sex___Date of Birth

Address_________________________________________City_____________________State_____Zip

Occupation__________________________Social Security No._____________________Phone No.

Claims Administrator/Insurer:

Name___________________________________Claim No.______________________Phone No.

Address_________________________________________City ____________________State_____Zip

Employer:

Name____________________________________________________________Phone No.

Address_________________________________________City____________________State_____Zip

You must address each of the issues below. You may substitute or append a narrative report if you require additional

space to adequately report on these issues.

Date of Injury________________Last date________________Date of current__________Permanent &

Date

worked

Date

examination

Date

Stationary date

Date

Description of how injury/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years

ago to asbestos):

Patient’s Complaints:

DWC Form PR-3 (Rev. 01/01/05)

Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report