New Mexico > Workers Compensation
Form Letter To Health Care Provider - New Mexico
| Form Letter To Health Care Provider Form. This is a New Mexico form and can be used in Workers Compensation . |
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ATTENTION! INJURED WORKERS- 1. HAVE YOUR DOCTOR FILL OUT THIS QUESTIONNAIRE. 2. HAVE YOUR DOCTOR MAIL THE COMPLETED QUESTIONNAIRE TO US AT LEAST FIVE (5) DAYS BEFORE THE MEDIATION CONFERENCE OR BRING THE COMPLETED QUESTIONNAIRE TO THE MEDIATION CONFERENCE THANK YOU - WORKERS COMPENSATION ADMINISTRATION <<<<<<<<<********>>>>>>>>>>>>> 2 STATE OF NEW MEXICO WORKERS COMPENSATION ADMINISTRATION FORM LETTER TO HEALTH CARE PROVIDER TO: HEALTH CARE PROVIDER RE: Worker: WCA No.: D OB: / / SSN: / / Attached is a release of medical information by the Worker/Patient. The information requested in this letter is necessary to evaluate the Workers legal claims. By promptly completing these forms, you speed the process of evaluation, including whether medical bills should be paid by the Insurance Carrier. Please answer all questions which you believe to be pertinent. Your answers must be based upon reasonable medical probability. 1. Who referred Worker to you for treatment? 2. Date of Workers most recent visit or treatment: 3. What is your diagnosis of the condition(s) for which you have treated the Worker? 4. In your opinion, are the conditions or complaints for which you have treated the Worker causally related to an on-the-job injury? Yes No Date of Injury: 5. Is the Worker suffering from a disease that, in your opinion, is related to employment? Yes No Date of occurrence: 6. Indicate the period of time the Worker has been unable to work: 7. Is Worker able to return to work? Yes No A ny restrictions? If no, when do you anticipate a return to work? 8. Has the Worker reached the date after which further recovery from, or lasting improvement to, an injury can no longer be reasonably anticipated (MMI) ? Yes N o Date of MMI: 9. If the Worker has reached MMI, please indicate your opinion as to the percentage of the Workers anatomical or functional abnormality existing after the date of MMI: a) Percentage of impairment, if any: <<<<<<<<<********>>>>>>>>>>>>> 3 b) Whole body or body part: c) Indicate which edition of AMA Guides used: 10. Has a Physical Capacities Assessment or Functional Capacity Evaluation been performed? Yes No Was the evaluation performed by a licensed physical therapist or occupational therapist? Yes No 11. Can the Worker: a) Lift over 50 pounds occasionally or up to 50 pounds frequently? Yes No b) Lift up to 50 pounds occasionally or up to 25 pounds frequently? Yes No c) Lift up to 20 pounds occasionally or up to ten pounds frequently, and either walk or stand to a significant degree, or sit most of the time with a degree of pushing and pulling arm or leg controls or both? Yes No d) Lift up to ten pounds occasionally or up to five pounds frequently, and occasionally walk or stand to carry out job duties? Yes No Comments: 12. Please describe any other restrictions on Workers activities not covered above: 13. Other remark s: 14. Have you made any referrals to other health care providers, hospitals or institutions? Yes No If yes, provide the name: 15. Please attach a copy of any unpaid bills. The maximum allowable fee for this form is $45.00. The fee for copying of medical r ecords and reports for the first ten (10) pages is $10.00, and $.20 cents for eac h additional page. I hereby swear and affirm that the foregoing responses or opinions are true and correct, to a reasonable medical probability, on pain and penalty of perjury. D ate: Signature of Physician Printed Name of Physician A ddress City/State/Zip ( ) Telephone Number SEND COMPLETED FORM TO: Workers Compensation Administration, P. O. Box 27198, Albuquerque, NM 87125-7198
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