Form Medco-14 - July 2015 Physicians Report Of Work Ability printable pdf download

Instructions for Completing the

Physician’s Report of Work Ability

This form provides important information about the injured worker’s ability to work.

• The treating physician must submit this form each time he/she sees the worker unless the worker has been awarded

permanent and total disability or has been previously released to his/her former position without restrictions.

• Please complete this form and provide a copy to the worker during his/her office visit. Fax a copy to the appropriate

managed care organization (MCO) or to the worker’s employer if self-insured.

• This form or an equivalent physician-generated document may support a request for temporary total compensation.

The equivalent document must contain, at a minimum, the data elements required on this form. If you have submitted

previously equivalent data elements that remain the same, indicate the name of the report that reflects the worker’s

current condition, e.g., May 15, 2015, office note.

• You may attach additional medical documentation such as diagnostic test results and a treatment plan to this form.

• Failure to provide complete detailed information may delay or suspend compensation payments to the worker.

Instructions

MEDCO-14 submission section: You must select only one of the three choices by selecting the appropriate box. If you

previously completed a MEDCO-14 and there are changes, you must indicate the changes in the appropriate section on the

form, and select the yes box in that section. For all other sections, you would make no entry, and select the no box.

Employment/occupation section: Please indicate if you have reviewed a description of the injured worker’s job held on the

date of the injury. Please indicate all sources providing you a description of the injured worker’s job. If you do not have a copy

of the worker’s job description, BWC or the MCO can help secure one.

Work status/Injured worker’s capabilities section: Please complete this section as accurately and thoroughly as possible,

as BWC will use this information to understand the worker’s work status and help facilitate his/her appropriate and safe return

to work either to his/her job held on the date of injury or an alternative job if he/she cannot return to the job held on the date

of injury.

3A: Please indicate if the injured worker has any restrictions related only to the allowed conditions in the claim. If there

are no restrictions related to the allowed conditions, indicate a release to work date for the injured worker.

3B: If there are restrictions related only to the allowed conditions in the claim, indicate whether or not the injured worker

can return to his/her job held on the date of injury. It is imperative that you follow all 3B instructions. This will facilitate

appropriate processing of the injured worker’s claim.

3C: To facilitate BWC’s efforts to safely return an injured worker to appropriate work, indicate which of the activities listed the

injured worker can perform. The following definitions apply to the section on Lifting/carrying, Pushing/pulling and Activity with

the percentages reflected as they relate to an eight-hour workday:

• Never – 0 percent;

• Occasionally – 1 percent to 33 percent, four to six repetitions per hour;

• Frequently – 34 percent to 66 percent, six to 12 repetitions per hour;

• Continuously – 67 percent to 100 percent, greater than 12 repetitions per hour.

We encourage you, in the space provided, to provide any additional information you believe would benefit the injured worker’s

safety and care relative to any return to work considerations.

Disability period information section: It is critical that if you answered No to 3B you complete this section.

4A: Please furnish the narrative description of the diagnosis(s), site/location and International Classification of Diseases code

for only allowed conditions being treated. You must indicate whether the allowed condition is preventing the injured worker

from returning to the job held on the date of injury.

4B: In this area you should list all other relevant conditions that impact treatment of the allowed conditions in the claim.

Clinical findings section: Provide medical rationale for the delay in the worker’s recovery and the barriers to return to work.

Maximum medical improvement (MMI) section: Provide the MMI date or explain why the worker has not reached MMI.

Provide the proposed treatment plan, including estimated duration.

Vocational rehabilitation section: If the worker is not a candidate for vocational rehabilitation, explain and recommend

actions to help the worker return to employment.

Treating physician’s signature section: Sign and date this form. Your signature indicates you have answered the questions

as truthfully and completely as possible.

For more informaiton or assistance

Please contact your local BWC customer service office, or call 1-800-644-6292. You can obtain BWC forms at

gov, at all BWC customer service offices, or by calling 1-800-644-6292 and listening to the options to reach a BWC customer

service

representative.tive.

BWC-3914 (Rev. June 30, 2015)

MEDCO-14

Form Medco-14 - July 2015 Physicians Report Of Work Ability

Related Articles

Related forms

Related Categories