North Dakota > Workers Comp
Capability Assessment SFN 58550 - North Dakota
| Capability Assessment Form. This is a North Dakota form and can be used in Workers Comp . |
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General Information 1600 E EAST CENTURY AVENUE, SUIT 1 Y TE PO BOX 55 585 CL LAIMS DIVIS SION BISMAR RCK ND 58506-55 585 SF 58550 (04/20 FN 012) one 033 Telepho 1-800-777-50 Toll Free F 1-888-786-86 Fax 695 TTY (hearing impaire 1-800-366-68 Y ed) 888 Fraud and Safety Hotline 1-800-243-33 331 WorkforceSafety.c com www.W PLE EASE TYPE OR PRINT USING BLACK OR BLU INK. SEE RE R UE EVERSE FOR A ADDITIONAL INS STRUCTIONS. Claim Numbe er Injury Date D Birth Date Social Security Number * CAPABILITY ASSESS Y SMENT Injured Worke Name er's Employ yer's Name Emp ployer's Phone Number Injured Worke Address er's Injur Worker's Pho Number red one Diagnosis Code/ICD9 Code Visit Date Part of Bo Injured ody Medical Assessment Purpose: Initial Evaluation n Re-check k Discharge on, plete the next qu uestion. If this is the initial evaluatio please comp ns? Yes No Any reported pre-existing/associated condition Injured worke is released to work with: er w No restrictions N With the follo owing restrictions (If so, please c s complete below) Restrictions are in effect until_ a ______________ ______________ __ Restrictions ordered are in effect for home and/o work activity. o or Physic Capabilitie cal es (Related to work injury d y): Not Recommended Seldom 1-5% Occas sional 6-33 3% F Frequent 34-66% Constant 67-100% Doctor's Estimate of Physical Capabilities Sit Stand / Walk Climb (ladder rs/stairs) Twist Bend / Stoop Squat / Kneel Crawl Reach (Left, Right, Both) Work above shoulders (L, R, B) s Wrist (L, R, B) B Grasp (L, R, B) Fine Manipula ation (L, R, B) Operate foot controls (L, R, B) B Drive / Opera Machinery ate Lifting/Pushing Not Recommended d Lift (L, R, B) lbs Carry (L, R, B) B Push / Pull lbs lbs Seldo om lbs lbs lbs Occasional lbs lbs lbs Freq quent lbs lbs lbs Constant lbs lbs lbs Other instruc ctions and/or lim mitations: Restrictions based upon: b Workability Functional Capacity Assess sment P Physical Exam Follow-up Follow-up Plan Next visit with this provider:____________ _______ Referral to o:____________ ____________ Consult with:___________ w ______________ ______ Med dication Prescrib bed:___________ ______________ ___ Oth her:___________ ______________ ________ MMI Has injured worker reached maximum medica improvement (MMI)? w m al ( Yes No D ate___________ _______ Yes No Unknow wn If yes, is it like that the perm ely manent partial imp pairment (PPI) will be greater tha 14% whole bo w an ody? FRAU WARNING UD Physic cian's Signature By signing this form, I acknowledg that I have read the Fraud Warning on the reverse sid of this form and understand that fa ge g de alsifying this claim or o making a false statement regarding this claim may be a felony punishable by substantial fines and im g m mprisonment. By m signature below I declare that the statements on this my w, e s form ar true and accurat re te. Facility F Date Federal Tax ID x Phone Nu umber Injured Worker's Signa d ature I authorize the release of this report and any other medica al information rela ated to my claim to my employer, Workforce y e Safety & Insura ance (WSI) and its age ents. C3 In com mpliance with the Federal Privacy Act of 1974, disclosur of the social security number on thiis form is mandator pursuant to N.D. F t re ry .C.C. 65-05-02. Th social security he numbe is used for identif er fication and verifica ation purposes. Fail lure to provide this information may re esult in a delay in p processing your req quest. ** Please com mplete sign, and return this for to WSI imme rm ediately. Promp payment of compensation depends on this form. pt American LegalNet, Inc. www.FormsWorkFlow.com Important Notes Complete a C3 form whenever restrictions are needed for return to work. For subsequent visits, a C3 form should be completed when there are meaningful changes in restrictions. This information will assist employers in determining appropriate accommodations. Keeping a worker on the job in transitional duty reduces the worker's likelihood of long-term disability. Please return the original form to WSI, provide a copy for the injured worker to give to their employer, and retain a copy for your records. Completion of the C3 is not a substitute for chart notes. Notes (e.g., SOAP format) are needed for continued management of the claim as well as for payment of services. All medical documentation, including the new C3 forms, should continue to be faxed to 1-888-786-8695 or 1-701-328-3820. Completing the C3 Form General Information Section · It is imperative providers indicate the injured worker's claim number on the C3 form. A claim number can be obtained by visiting www.WorkforceSafety.com (Click on "Find a claim number"). If a claim has not been filed, the injured worker must complete a First Report of Injury. The C3 form cannot be used to file a claim. Work Activity Section It is only necessary to indicate the applicable physical demands that must be restricted. Those left blank will be considered as unrestricted. · Restrictions established are applicable 24 hours a day and not just at work. · Writing "See Chart Notes" on the C3 form is not appropriate because chart notes typically arrive later in the claim file than the C3 and are not immediately available to employers. · · MMI Section This information helps WSI assess eligibility for benefits. o Maximum medical improvement (MMI) refers to a treatment plateau in a person's healing process. It can mean the injured worker has fully recovered from the injury or the medical condition has stabilized to the point that no major medical improvement can be expected. o Providers are requested to provide an opinion regarding permanent partial impairment (PPI) versus actually determining the degree or extent of impairment according to a rating schedule. Fraud Warning for Filing False Claims Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers' compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with the Fund, including injured workers, employers, medical providers, and attorneys. American LegalNet, Inc. www.FormsWorkFlow.com
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