Virginia > Workers Compensation
Attending Physicians Report 6 - Virginia
| Attending Physicians Report Form. This is a Virginia form and can be used in Workers Compensation . |
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Virginia Workers' Compensation Commission 1000 DMV Drive, Richmond, VA 23220 Phone: 1-877-664-2566 Website: http://www.workcomp.virginia.gov WebFile: https://webfile.workcomp.virginia.gov Attending Physician's Report Employee 3. Address 1. Patient's Name 4. Date of Birth 6. Social Security Number VWC Jurisdiction Claim Number (JCN) 2. Phone Number 5. Sex Male / Female Background Information 7. Name of Employer 9. Date of Injury or illness 10. Patient's account of how injury or exposure to occupational disease occurred 8. Address of Employer 11. Date of first visit 12. Date of discharge 13. Person authorizing treatment Findings and Diagnosis 14. Findings upon examination, including results of x-rays, laboratory studies, etc. Please not any prior injuries and pre-existing conditions. Provide additional comments on the reverse side of this form. 15. Diagnosis 17. Nature of treatment 16. Is diagnosis condition due to the occurrence described by patient? Yes / No / Unknown 18. Dates of your treatment 19. Provide names and addresses of other health care providers to whom patient was referred 20. Was there any fracture or amputation? Yes / No / Unknown 22. Was there disability for work? Yes / No / Unknown 26. Will there be any permanent defect or disfigurement? Yes / No / Unknown 21. Please describe 23. Date disability began 27. Please describe 24. Date able to return to light work 25. Date able to return to regular work 28. Has patient reached maximum medical improvement? Yes / No 30. Address Attending Physician 31. Date of this report 29. Name of Attending Physician I certify that I personally examined and treated this patient. Signature VWC Form No. 6 (rev. 01/14/13) , MD This report is required by the Virginia Workers' Compensation Act American LegalNet, Inc. www.FormsWorkFlow.com (Instructions Updated 01/14/2013) FILING INSTRUCTIONS Attending Physician's Report VWC Form 6 The treating physician completes this form and the report provides specific medical information including date of accident, diagnosis, prognosis, the disability period(s), and the extent of any permanent disability. Filing options: 1. By Internet: This form may be filed electronically through the Commission's WebFile system at http://webfile.workcomp.virginia.gov. To file electronically, the user must have a valid and active WebFile account. 2. By mail: 1000 DMV Drive, Richmond, Virginia 23220 3. By fax: (804) 367-6124 This form is available on the Commission's website at www.workcomp.virginia.gov. For questions about or assistance with completing this form, please contact the Commission toll-free by phone at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov. American LegalNet, Inc. www.FormsWorkFlow.com
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