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Medical Form 75 WCA-1 - New Hampshire

Medical Form Form. This is a New Hampshire form and can be used in General Workers Comp .
 Fillable pdf Last Modified 4/11/2005
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LAB 500 NEW HAMPSHIRE WORKERS' COMPENSATION MEDICAL FORM This form must be completed at each health professional visit (MD, DO, DC or DDS) and must be filed with the workers' compensation insurance carrier within 10 days of the treatment (first aid excluded). Failure to comply and complete this form shall result in the provider not being reimbursed for services rendered and may result in a civil penalty of up to $2,500. In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary alternative/transitional work opportunities to all employees temporarily disabled by a work related injury or illness. Employee Employer Work telephone # Employer contact Employer address SS# Occupation Date last worked W.C. insurer HEALTH PROFESSIONAL TO COMPLETE Initial visit Follow-up visit Worker's statement of the incident Worker's complaints Diagnosis/Prognosis Treatmentplan In your opinion is this injury and disability as a result of injury described above? Yes EMPLOYEE WORK CAPABILITY Continue Working Can return to work: Yes Date Full Duty With Modification. If so, for what duration? Employee Can No Restrictions Frequently Occasionally Unable to Date of Injury Time No No Unclear bend kneel squat climb Employee can lift/carry maximally Employee can lift/carry frequently lbs. lbs. stand walk hours/day, Employee can work a maximum of # # days/wk. What special accommodations are required? sit reach drive do fine motor Wrist No repetitive motions Right Left Elbow Shoulder Ankle Other Has employee reached maximum medical improvement? Yes No Has injury caused permanent impairment? Yes No Undetermined ALL MEDICAL NOTES MUST BE ATTACHED TO BILL I certify that the narrative descriptions of the principal and secondary diagnosis and the major procedures performed are accurate and complete to the best of my knowledge. Provider's signature Provider's Printed name Provider's telephone # Federal ID# Date of Visit MEDICAL AUTHORIZATION: The act of the worker in applying for workers' compensation benefits constitutes authorization to any physician, hospital, chiropractor, or other medical vendor to supply all relevant medical information regarding the worker's occupational injury or illness to the insurer, the worker's employer, the worker's representative, and the department. Medical information relevant to a claim includes a past history of complaints of, or treatment of, a condition similar to that presented in the claim. [281-A:23 V(a)] 75 WCA-1 (6/1994) White ­ Insurer/Managed Care Yellow ­ Provider Pink ­ Employee/Employer American LegalNet, Inc. www.FormsWorkFlow.com
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