Maine > Workers Compensation
Practitioners Report M-1 - Maine
| Practitioners Report Form. This is a Maine form and can be used in Workers Compensation . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. M-1 : REASON FOR REPORT CIRCLE ONE INITIAL PROGRESS FINAL TYPE Index No. OF PRACTITIONER CIRCLE ONE -againstE M P L O Y E E EMPLOYER NAME: PRACTITIONER'S REPORT : STATE OF MAINE WORKERS' COMPENSATION : BOARD Plaintiff(s) Office of Medical/Rehabilitation : Services EMPLOYEE LAST NAME: Calendar No. MD DO DC JUDICIAL SUBPOENA LIST OTHER _____________________ : FIRST NAME: M.I.: EMPLOYER MAILING ADDRESS & PHONE #: ADDRESS - NUMBER AND STREET: : INSURER NAME: . ........ Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . CITY:. . . . . . . . . . . . . . . . . . . STATE: ... DATE OF INJURY: SSN: ZIP: HOME PHONE: INSURER MAILING ADDRESS: THE PEOPLE OF THE STATE OF NEW YORK PATIENT'S COMPLAINTS: TO ICD-9 CODE: IN GREETINGS: PROBLEM IS MY OPINION, THIS WORK RELATED YES NOT WORK RELATED NO RESULTS: IS NOT YET IDENTIFIED AS TO CAUSE P R A C T I T I O N E R WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court IS TREATMENT TO CONTINUE? YES NO DATE OF THIS EXAMINATION : / / located at County of DATEroom / in PATIENT TO BE SEEN AGAIN: , on the day/ of ESTIMATED ,LENGTH OF TREATMENT? 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the TREATMENT PLAN: LIST ANY MEDICATION PRESCRIBED FOR THIS DIAGNOSIS/CONDITION THAT WOULD PREVENT YOUR PATIENT FROM DRIVING AND/OR WORKING SAFELY: HAVE DIAGNOSTIC TESTS BEEN PERFORMED? Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. / / P.I. RATING : / / MODIFIED DUTY IF UNABLE TO WORK, ADVISE ESTIMATED DATE OF RETURN : Witness, HonorableDUTY REGULAR WORK CAPACITY: Court in County, day of RESTRICTIONS YES/NO DESCRIBE: , one of the Justices of the NO WORK CAPACITY , 20 (Attorney must sign above and type name below) Attorney(s) for IS PERMANENT IMPAIRMENT EXPECTED? HAS MMI BEEN REACHED? SIGNATURE OF PRACTITIONER TELEPHONE #: WCB M-1 (6/99) DISTRIBUTION: YES YES NO NO Office and P.O. Address Telephone No.: Facsimile No.: PRINT NAME AND ADDRESS E-Mail Address: NARRATIVES ATTACHED? YES NO Mobile Tel. No.: INSURANCE COMPANY (4) PRACTITIONER (1) EMPLOYEE (2) EMPLOYER (3) American LegalNet, Inc. www.USCourtForms.com
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