Fillable Dwc Form-73 - Texas Workers' Compensation Work Status Report (Page 2 of 2) in pdf

DWC FORM - 73

WORK STATUS REPORT INSTRUCTIONS

PART I: GENERAL INFORMATION - Contains space to record general information about the employee and the doctor/clinic.

This section includes space to record a high-level generic description of the injury or condition (e.g. broken right arm, strained left

knee, etc) and how it occurred. Also contains space to record the name and facsimile number or email address of the insurance

carrier (carrier) and the employer, as well as the date of transmission. This space is intended to eliminate the need for a separate

facsimile cover page. Because this information is intended primarily for transmission purposes, the report may be

provided to the injured employee (employee) at the time of the examination, even if the information required in this

section is not yet available.

PART II: WORK STATUS INFORMATION - The doctor is required to indicate the employee’s current work status. There are

three choices: able to work without restrictions; able to work with restrictions; and prevented from returning to work.

If the doctor believes that the employee can only work with restrictions or is prevented from returning to work, the doctor is

required to provide an estimated date of expiration for the restrictions.

These estimates are required to enhance claims

management and to provide the employer with information that can be used to plan work coverage and plan for the employee’s

return to work (whether with or without restrictions). An estimated expiration is speculative in nature. The further the date is

projected, the less accurate it may be. Estimations are not binding and may be changed as needed based upon the

condition and progress of the employee by filing a subsequent Work Status Report. Doctors need to provide reasonable

estimates based upon the nature of the employee’s injury.

In addition, a doctor who believes that an employee is prevented from returning to work is required to provide a specific

explanation of how the condition prevents the employee from returning to work. One of the goals of the Texas Workers’

Compensation Act is to ensure a speedy return to employment which is safe, meaningful, and commensurate with the abilities of

the employee. It is the responsibility of the doctor treating or examining an injured employee to identify what the

employee may be able to safely perform. It is not the doctor’s responsibility to ensure that the employer has a modified

duty position that meets those restrictions - that is the employer’s responsibility if the employer chooses to try to

accommodate the restrictions.

PART III: ACTIVITY RESTRICTIONS - If the doctor indicates that the employee is able to work with restrictions, the doctor is to

indicate those restrictions in this section. The doctor is only supposed to indicate what restrictions are in place because of

the workers’ compensation injury. Any restrictions that may have existed due to other conditions are assumed to remain and

should not be duplicated here. The doctor should go over the restrictions with the employee at the time the report is provided.

The section was designed to include check boxes for common restrictions that may apply to the employee. If a box is not

checked, it is assumed that there is no restriction on that activity. Also, if no specific body part is indicated in box #15, then it

should be understood that the restrictions are whole body restrictions.

PART IV:

DIAGNOSIS/FOLLOW-UP INFORMATION - Provides general diagnosis information and provides upcoming

appointment information (if known at time of filing report) so that the carrier can better manage the claim and the employer can be

aware of time where the employee might not be available for work. In addition, providing this information may reduce calls from

carriers and employers seeking the information. However, doctors need ensure that the diagnosis information provided to

the employer is at a general level and does not violate any confidentiality laws relating to the employee’s privacy rights.

The Work Status Report is primarily designed to be filed by the treating or referral doctor. However, other doctors can and will

occasionally need to file this report. The following describes the various roles that doctors can play within the system:

Treating: Doctor chosen by and primarily responsible for employee's

Referral: Doctor who was selected by the treating doctor to treat one

injury-related health care.

or more aspects of the employee’s medical condition.

Consulting: Doctor who was selected by the treating doctor to

Carrier-selected RME: Doctor selected by the insurance carrier.

provide an opinion on the employee’s medical condition.

Designated: Doctor selected by the Division to evaluate whether the

DWC-selected RME: Doctor selected by DWC.

employee’s medical condition has improved sufficiently to allow a

Other: Doctor who fits none of the other descriptions.

return to work (only for Supplemental Income Benefits claims).

Basic Instructions - Provide to injured employee at time of examination and fax or electronically transmit to: insurance carrier

and employer by the end of the second working day following the date of the examination. Report must be filed after initial visit,

when there is a change in work status or a substantial change in activity restrictions, and on the schedule requested by or through

the carrier (not to exceed one report every two weeks). Also file within 7 days of receiving functional job descriptions from the

employer or a Work Status Report from a Required Medical Examination doctor that indicates that the employee is able to return

to work with or without restrictions.

Rules 126.6, 129.5, and 130.110 lay out the complete requirements for filing this report (in addition, Rule 129.6 provides

information on how the report might be used). The complete text to these rules is available on the Division’s web site at

DWC FORM-73 (Rev. 10/05) Page 2

DIVISION OF WORKERS’ COMPENSATION

Dwc Form-73 - Texas Workers' Compensation Work Status Report Page 2

Related Articles

Related forms

Related Categories