Pennsylvania > Workers Comp
Impairment Rating Determination Face Sheet LIBC-767 - Pennsylvania
| Impairment Rating Determination Face Sheet Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 Social Security Number: ________ - _______ - _________ IMPAIRMENT RATING DETERMINATION FACE SHEET Date of Injury: ______/______/____________ MM DD YYYY PA BWC Claim Number: ____________________________ (IF KNOWN) Employee First Name _________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County __________________________________________ State Telephone (_______) _______ - _______________ Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________ Employer Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County ____________________________________________ Telephone (_______)_______-____________________________ FEIN _____________________ State Zip Code ________________________________________________ _________ ____________-_________ Insurer or Third Party Administrator (if self-insured) Name 767 0506 DATE OF THIS NOTICE: ______/______/___________ MM DD YYYY _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ County ____________________________________________ Claim Number ____________________________________________ FEIN _____________________ State Zip Code Bureau Code _____________________ ________________________________________________ _________ ____________-_________ Attorney for Employee (if known) Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ PA Attorney ID Number ________________________________ Attorney for Insurer/Employer (if known) Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ PA Attorney ID Number ________________________________ Claim Representative SEE IMPORTANT INFORMATION ON REVERSE. First Name _________________________________ Telephone (_______) _______ - _______________ Last Name _____________________________________________ (OVER) LIBC-767 REV 5-06 (Page 1) American LegalNet, Inc. www.FormsWorkflow.com I examined the referenced employee, ________________________________________________________, with regard to establishing an Impairment Rating Determination to define the degree of impairment due to the compensable injury, if any, in accordance with the provision of Section 306(a.2) of the Pennsylvania Workers' Compensation Act. Attached is the Report of Medical Evaluation prepared as utilized by the most recent edition of the American Medical Association Guides to the Evaluation of Permanent Impairment. The original of this face sheet and report is being provided to the Bureau of Workers' Compensation, 1171 S. Cameron Street, Room 103, Harrisburg, PA 17104-2501, with copies to the employee, the employee's attorney (if known) and the insurer within 30 days of the date of the impairment evaluation. Name of Patient: _________________________________________________________ Social Security Number: ______-_____-__________ Reported Date of Injury: ______/______/___________ MM DD YYYY Date of this Examination: ______/______/___________ MM DD YYYY Percentage of Impairment Rating: _________% My charge of $_________________ will be billed to the Insurer or Third Party Administrator (if self-insured) for conducting this examination. I attest that I am a physician licensed in the Commonwealth of Pennsylvania and certified by an American Board of Medical Specialties approved board or its osteopathic equivalent, and that I have an active clinical practice of at least twenty (20) hours per week. Physician First Name _________________________________ Signature _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ State Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________ Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-767 REV 5-06 (Page 2) American LegalNet, Inc. www.FormsWorkflow.com
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