Oklahoma > Workers Comp
Treating Physicians Report And Notice Of Treatment 4 - Oklahoma
| Treating Physicians Report And Notice Of Treatment Form. This is a Oklahoma form and can be used in Workers Comp . |
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FORM 4 SEND COPIES TO 1--Injured Worker 1--Employer 1--Employer's Insurer WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 This space for Court Use only In re claim of: Full Name of Injured Employee (Claimant) Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX______________________ Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured WCC FILE NO. (Must be filled out) TREATING PHYSICIAN'S REPORT AND NOTICE OF TREATMENT (Please type or print) 1. HISTORY OF ACCIDENT: Date and Time of Accident Occupation or job of employee (Please type or print) State, in the employee's own words, how the accident occurred. Were the employee's injuries causally connected to the above described accident? 2. MEDICAL HISTORY State the objective complaints of the employee. State whether previous sickness or injury contributed to the employee's present condition. Was the employee hospitalized? Other significant medical history of the employee. Age Date of birth Describe the medical treatment rendered to date. List all other treating or consulting physicians. 3. CLINICAL EVALUATION: Describe your examination and all diagnostic tests performed. State your findings and diagnoses. Describe the medical treatment you recommend for the future. Were medical records reviewed? 4. EVALUATION OF TEMPORARY TOTAL DISABILITY: Date of employee's first treatment by you. State the date you released the employee as able to return to work. Has the employee been totally unable to return to work for any period? Employee was temporarily totally disabled from: Is the employee's inability to work the result of the above described accident? I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Employee Employer Insurance Carrier Signed this ____________ day of _________________, ________ Type or Print Name of Treating Physician Signature of Treating Physician Address (Number and Street) City State Zip Code Address City State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com 08/11
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