Kentucky > Workers Comp
Physicians Medical Report (Hearing Loss) 108-HL - Kentucky
| Physicians Medical Report (Hearing Loss) Form. This is a Kentucky form and can be used in Workers Comp . |
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FORM 108 - HL FILED:Medical Report - Hearing Loss Adopted June, 2000 KENTUCKY DEPARTMENT OF WORKERS CLAIMS Do not write in this space MEDICAL REPORT OF DR. A. PATIENT INFORMATION 1. Patient Name: 2. Address: 3. Social Security Number: 4. Date of Birth: Age: 5. Patient height in centimeters: 6. Patients job title and employer: 7. Date of Examination(s) : 8. Purpose of Examination:o Treatment o Evaluation requested by o University evaluation 9. Prior Evaluation (if any) and Date: B. PATIENT HISTORY Patient related history of complaints allegedly due to hearing loss as follows: <<<<<<<<<********>>>>>>>>>>>>> 2C. EMPLOYMENT HISTORY Employment History (Form 104) dated is attached. Review form with patient and list pertinentemployment history, including exposure, if any, to environmental noise, either through a single incident of trauma or repetitive exposure over an extended period. D. TREATMENT - Prior and Current Based upon a review of records and/or history related by patient, treatment (including any periods of hospitalization)provided for the above complaints has been as follows: E. PHYSICAL EXAMINATION Results of physical examination including objective medical findings. F. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. Test Date Summary of ResultsA. oComprehensive Audiometry B. oImmitance Audiometry C. oOtoacoustic Emissions D. oCommunication Needs Assessment E. oOther (specify) <<<<<<<<<********>>>>>>>>>>>>> 3G. DIAGNOSISH. CAUSATION1. Audiograms and other testing establish a pattern of hearing loss compatible with that caused by hazardous noise exposure in the workplace o yes o no2. Within reasonable medical probability, patients hearing loss is related to noise exposure in the workplace or workplace accident. o yes o no<<<<<<<<<********>>>>>>>>>>>>> 4I. IMPAIRMENT1. Using the most recent AMA Physician Guides to Evaluation of Permanent Impairment, the patient has a permanent functional impairment of %. Do not include any impairment ratings for tinnitus. 2. The above impairment was calculated as follows: Chapter Table Page a. b. c. d. 3. Does patient have a total loss of hearing ? o yes o no. 4. Was any portion of patients hearing loss an active impairment prior to acquiring the work-related condition? yes no If yes, explain and quantify. A. For affirmative answer, specify condition producing active impairment. B. For affirmative answer, specify percentage of impairment due to the prior active condition.J. RESTRICTIONS 1. The patient o has o has not described the physical and hearing requirements of his usual and customary work activities. For affirmative answer, briefly specify patients self-described work activities.2. Should restrictions be placed upon patients work activities due to the hearing loss? oyes o no 3. Does patient retain the physical capacity to return to the type of work performed at the time of injury ? o yes o no <<<<<<<<<********>>>>>>>>>>>>> 5K. RECOMMENDATIONS FOR TREATMENT L. CERTIFICATION and QUALIFICATIONS of PHYSICIAN I hereby certify that the above information is correct and that all opinions were formulated within the realmof reasonable medical probability. A copy of my curriculum vitae is attached if I have not obtained a Departmentof Workers Claims Physician Index Number. Date: Full name of Physician Department of Workers Claims Physician Index No. <<<<<<<<<********>>>>>>>>>>>>> 6 Instructions for Completion of Forms 107-I, 107-P, 108-OD, 108-CWP and 108-HL The medical report forms of the Department of Workers Claims are designed to provide relevant medical information to arbitrators and administrative law judges to assist in determining the occupational implications of a work-related injury or an occupational disease. Therefore, it is important that each section of the forms be carefully and fully completed. 1. All information must be typed or neatly printed.2. The Department of Workers Claims maintains a Physician Index with curricula vitae of physicians. Physicians may be included in this index by tendering a copy of current curriculum vitae with a request for inclusion to: Physicians Index Clerk, Department of Workers Claims, 1270 Louisville Road, Perimeter Park, Building C, Frankfort, Kentucky, 40601. 3. Use of the most recent edition of the AMA Guides to the Evaluation of Permanent Impairment is mandated by statute. Reference should be made to page numbers and tables only from the most recent edition for all physical injuries. For psychiatric conditions, the class of impairment should be stated, with reference to impairment ratings provided in prior editions. 4. Height of a patient should be measured in centimeters and without shoes. If the patients height is an odd number of centimeters, the next highest even height in centimeters shall be used.5. Objective medical findings to support a medical diagnosis means information gained through direct observation and testing of the patient, applying objective or standardized methods. KRS 342.0011(33)6. Medical opinions must be founded on reasonable medical probability, not on mere possibility or speculation. Young v. Davidson, Ky., 463 SW2d 924(1971). 7. Preexisting dormant nondisabling condition is defined as a condition which is capable of arousal into disabling reality by work activities or injury. The condition must be a departure from the normal state of health. KRS 342.020, Newberg v. Armour Food Co., Ky., 834 SW2d 172 (1992).8. Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Revised January 1, 1997
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