Texas > Workers Compensation > Medical
Work Status Report DWC-73 - Texas
| Work Status Report Form. This is a Texas form and can be used in Medical Workers Compensation . |
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Employee - You are required to report your injury to your employer within 30 days if your employer has workers' compensation insurance. You have the right to free assistance from the Texas Department of Insurance, Division of Workers' Compensation and may be entitled to certain medical and income benefits. For further information call your local Division field office or 1(800)-252-7031. Empleado - Es necesario que reporte su lesión a su empleador dentro de 30 días a partir de la fecha en que se lesionó si es que su empleador cuenta con un seguro de compensación para trabajadores. Usted tiene derecho a recibir asistencia gratuita por parte de la División de Compensación para Trabajadores, y también puede tener derecho a ciertos beneficios médicos y monetarios. Para mayor información comuníquese con la oficina local de la División al teléfono 1-800-252-7031. TEXAS WORKERS' COMPENSATION WORK STATUS REPORT 5. Doctor's Name and Degree (for transmission purposes only) Date Being Sent PART I: GENERAL INFORMATION 1. Injured Employee's Name 6. Clinic/Facility Name 9. Employer's Name 2. Date of Injury 3. Social Security Number (last 4) 7. Clinic/Facility/Doctor Phone & Fax 10. Employer's Fax # or Email Address (if known) xxx-xx4. Employee's Description of Injury/Accident 8. Clinic/Facility/Doctor Address (street address) 11. Insurance Carrier City State Zip 12. Carrier's Fax # or Email Address (if known) PART II: WORK STATUS INFORMATION (a) will allow the employee to return to work as of (b) will allow the employee to return to work as of through (date). (FULLY COMPLETE ONE INCLUDING ESTIMATED DATES AND DESCRIPTION IN 13(c) AS APPLICABLE) 13. The injured employee's medical condition resulting from the workers' compensation injury: (date) without restrictions. (date) with the restrictions identified in PART III, which are expected to last (date) and is expected to continue through (date). (c) has prevented and still prevents the employee from returning to work as of The following describes how this injury prevents the employee from returning to work: PART III: ACTIVITY RESTRICTIONS* (ONLY COMPLETE IF BOX 13(b) IS CHECKED) 14. POSTURE RESTRICTIONS (if any): Max Hours per day: 0 2 4 6 8 Other Standing Sitting Kneeling/Squatting Bending/Stooping Pushing/Pulling Twisting 17. MOTION RESTRICTIONS (if any): Max Hours per day: 0 2 4 6 8 Other Walking Climbing stairs/ladders Grasping/Squeezing Wrist flexion/extension Reaching Overhead Reaching 19. MISC. RESTRICTIONS (if any): Max hours per day of work: Sit/Stretch breaks of per Must wear splint/cast at work Must use crutches at all times No driving/operating heavy equipment Can only drive automatic transmission No work / hours/day work: in extreme hot/cold environments at heights or on scaffolding Must keep No skin contact with: Dressing changes necessary at work lbs. No running 20. MEDICATION RESTRICTIONS (if any): Must take prescription medication(s) Advised to take over-the-counter meds Medication may make drowsy (possible safety/driving issues) elevated clean & dry Other: 15. RESTRICTIONS SPECIFIC TO (if applicable): Left Hand/Wrist Right Hand/Wrist Left Arm Right Arm Neck Left Leg Right Leg Back Left Foot/Ankle Right Foot/Ankle Keyboarding Other: 18. LIFT/CARRY RESTRICTIONS (if any): May not lift/carry objects more than hours per day for more than May not perform any lifting/carrying Other: Other: 16. OTHER RESTRICTIONS (if any): * These restrictions are based on the doctor's best understanding of the employee's essential job functions. If a particular restriction does not apply, it should be disregarded. If modified duty that meets these restrictions is not available, the patient should be considered to be off work. Note - these restrictions should be followed outside of work as well as at work. PART IV: TREATMENT/FOLLOW-UP APPOINTMENT INFORMATION 21. Work Injury Diagnosis Information: 22. Expected Follow-up Services Include: Evaluation by the treating doctor on Referral to/Consult with Physical medicine Special studies (list): Date / Time of Visit Discharge Time EMPLOYEE'S SIGNATURE DOCTOR'S SIGNATURE Visit Type: Initial Follow-up (date) at on weeks starting on on : (date) at am/pm : (date) at am/pm : : am/pm am/pm (date) at X per week for None. This is the last scheduled visit for this problem. At this time, no further medical care is anticipated. Role of Doctor: Designated doctor Treating doctor Referral doctor Consulting doctor Carrier-selected RME DWC-selected RME Other doctor DWC FORM-73 (Rev. 02/11) Page 1 DIVISION OF WORKERS' COMPENSATION Frequently Asked Questions Work Status Report (DWC Form-073) Under what circumstances am I required to file the DWC Form-073? Filing requirements for DWC Form-073 vary depending on the type of doctor filing the Work Status Report. The specific requirements are shown in the chart below. Type of Doctor Treating Doctor or Referral Doctor · · · · When to File DWC Form-073 after the initial examination of the injured employee, regardless of the employee's work status when there is a change in the injured employee's work status when there is a substantial change in the injured employee's activity restrictions on a schedule requested by the insurance carrier as long as it is based on the injured employee's scheduled appointments with the doctor (not to exceed one report every two weeks) after receiving a set of functional job descriptions, from the employer or insurance carrier listing modified duty positions, including the physical and time requirements of the positions, that the employer has available for the injured employee to work after receiving a DWC Form-073 from a RME Doctor that indicates the injured employee is able to return to work with or without restrictions after examination of an injured employee to address any question relating to return to work · Where to File injured employee Delivery Method hand deliver Deadline at the time of the examination within 2 working days of the examination · insurance carrier fax or e-mail · employer fax or e-mail unless recipient has not provided these numbers; then by personal delivery or mail hand deliver unless no appointment is scheduled before deadline; then fax or e-mail unless recipient has not provided these numbers; then by mail fax or e-mail within 7 days of receiving job description or RME opinion · · injured employee · · · · · insurance carrier employer injured employee injured employee's representative (if any) Designated Doctor · NOTE: The Des
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