West Virginia > Workers Comp
Attending Physicians Report BI-219 - West Virginia
| Attending Physicians Report Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-219 01/06 Attending Physician's Report SECTION I: COMPLETED BY THE INJURED WORKER Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 Claim No.: Emp loyer's Policy No.: Claimant's Name: Claimant's Address: City, State, Zip: S.S. No.: D.O.I.: Employer's Name: Employer's Address: City, State, Zip: Current Telephone No.: Have you performed any kind of work or have you received income for any work during the time you have been certified temporarily and totally disabled? Yes No I hereby certify that the statements and answers set forth above are true and correct to the best of my knowledge and belief. I am aware that the law provides for severe penalties if I knowingly and with fraudulent intent withhold a material fact or make a false statement in order to obtain or increase a benefit that I am not entitled to. S i g n a t ur e : FORM MAY BE RETURNED IF ALL QUESTIONS ARE NOT ANSWERED ATTACH ADDITIONAL PAGES IF NECESSARY. IF CLAIMANT HAS REACHED MAXIMUM DEGREE OF MEDICAL IMPROVEMENT, PLE ASE COMPLETE FORM BI219A, NOTICE OF MAXIMUM MEDICAL IMPROVEMENT. SECTION II: TO BE COMPLETED BY THE ATTENDING PHYSICIAN (PLEASE COMPLETE ALL QUESTIONS.) No. of TTD days paid: Date of Examination: Optimum No. of TTD days for is Remaining TTD days: Date of Next Appointment: Is this the first examination and/or treatment by you for this injury? If yes, please advise as to how the claimant came under your care. Does claimant continue under your active care? If no, please explain. Yes Yes No No Has the claimant been referred to another physician for any of the following? (check appropriate box(es) and explain basis for your referral.) Consultation Diagnosis (ICD9-CM) code and description Evaluation Treatment Please describe your treatment plan and list medications currently being prescribed, their dosages, and the refill limit. Has normal or expected recovery been delayed due to complications, concurrent medical problems, pre-existing medical condition, subsequent trauma, etc? Yes No If yes, please explain condition and how it has affected recovery. Yes Yes No No If yes, please specify. If yes, is disability due to compensable diagnosis or other causes? Please explain. Will claimant need rehabilitation services? Is claimant temporarily and totally disabled? Please indicate the anticipated date claimant will be able to return to: Modified Work: Yes No Trial Return to Work: Work: If the claimant has reached maximum medical improvement, is there, or do you anticipate, any permanent impairment as a result of the compensable injury? If yes, please complete form BI-219a, Notice of Maximum Medical Improvement. Yes No Physician's Signature Date: Is the claimant ready for an independent medical examination? Physician's Name, Address and Telephone No. FEIN: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.USCourtForms.com
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