Kentucky > Workers Comp
Physicians Medical Report (Injury) 107-I - Kentucky
| Physicians Medical Report (Injury) Form. This is a Kentucky form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
FORM 107 - I FILED:Medical Report - Injury Adopted June, 2000 COMMONWEALTH OF 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. Patients job title and employer: 6. Date of Examination(s) : 7. Purpose of Examination: o Treatment o Evaluation requested by o University evaluation B. PATIENT HISTORY Patient related history of complaints or alleged injury as follows: C. TREATMENT - Prior and Current Based upon a review of records and/or history related by patient, treatment provided for this injury has beenas follows: (Include any periods of hospitalization). <<<<<<<<<********>>>>>>>>>>>>> 2D. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings to support complaints and/or diagnosisE. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. Test Date Summary of ResultsA. o X-rays B. o CT Scan C. o MRI D. o Myelogram E. o EMG F. o Other (specify) F. SURGICAL PROCEDURE(S) Specify type and date of any surgical procedure. Include operative note if surgery performed by this examiningphysician. G. DIAGNOSIS H. CAUSATION Within reasonable medical probability, patients injury o was o was not the cause of his/her complaints. Explain. <<<<<<<<<********>>>>>>>>>>>>> 3I. IMPAIRMENT 1. Using the most recent AMA Guides to Evaluation of Permanent Impairment, the patients permanent whole body impairment is %. 2. Chapter and Tables utilized to arrive at impairment rating for injuries other than spinal injuries.NOTE: For spinal injuries, utilize Injury (DRE) model unless another method is authorized in theGuides. Body Part or System Chapter No. Table No. Impairment % of Whole Person a. b. c. d. e. f. 3. Patient o did o did not have an active impairment prior to this injury. A. For affirmative answer, specify condition producing active impairment. B. For affirmative answer, specify percentage of impairment due to the prior active condition.J. APPORTIONMENT Answer only if injury occurred before December 12, 1996. 1. Patients condition o is o is not due in part to arousal of a preexisting dormant nondisabling condition or congenital abnormality. A. For affirmative answer, specify preexisting dormant condition or disease and describe how it constitutes a departure from the normal state of health. B. For affirmative answer, specify percentage of impairment due to arousal of the preexistent dormant nondisabling condition. <<<<<<<<<********>>>>>>>>>>>>> 4K. RESTRICTIONS1. The patient o has o has not described the physical 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 injury or its residuals? o yes o no 3. For affirmative answer, describe the nature and extent of restrictions to be placed upon patient in performance of the following functions: lifting, bending, walking, standing, sitting, climbing, reaching, grasping, and operating machinery. 4. Does patient retain the physical capacity to return to the type of work performed at the time of injury? o yes o no L. CERTIFICATION and QUALIFICATIONS of PHYSICIAN I hereby certify that the above information is correct and that all opinions were formulated within therealm of reasonable medical probability. A copy of my curriculum vitae is attached if I have not obtained aDepartment of Workers Claims Physician Index Number. Date: Full name of Physician Department of Workers Claims Physician Index Number <<<<<<<<<********>>>>>>>>>>>>> 5 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
|
|||||||
