West Virginia > Workers Comp
Physicians Report Of Occupational Pneumoconiosis BI-205 - West Virginia
| Physicians Report Of Occupational Pneumoconiosis Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-205 Return completed form to: 01/06 Physician's Report of Occupational Pneumoconiosis Claimant's Name (First, Middle, Last) Claimant's Address City, State, Zip Date of Birth (Month, Day, Year) Male Female Single Married Widowed Diagnosis Social Security Number BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 BrickStreet Use Only Silicosis OP OD Date of first treatment or examination (Month, Day, Year) In your opinion has claimant contracted occupational pneumoconiosis? Yes No How long has claimant been suffering from the disease of occupational pneumoconiosis? Has the claimant's capacity for work been impaired by occupational pneumoconiosis? If yes, to what extent? History: Has the claimant ever had Yes Pneumonia Pleurisy Asthma Tuberculosis Yes No No Date Angina Pectoria Coronary Occlusion Rheumatic Heart Disease Congestive Heart Failure Arthritis Yes No Date Other serious illnesses Surgery Accidents Yes Yes Yes No No No Date and describe Date and describe Date and describe Present complaints and duration of complaints Has the sputum of the claimant been examined for tubercle bacillus? If yes, by whom? What lab? Findings? Where are the lab reports filed? If employee is deceased, was an autopsy performed? Has claimant participated in any OP treatment program? Yes Yes Yes No No No American LegalNet, Inc. www.USCourtForms.com Have x-rays been made of the claimant's lungs? Right lung Yes No Yes Left Lung Date No Yes No Where Filed If yes to either, please answer below. Findings Hospital or Doctor Have pulmonary function studies, blood gas studies or other pertinent clinical examinations been performed? Hospital or Doctor Date Yes No If yes, please answer below. Findings Where Filed Appearance: Height: Weight: Good Fair ft. lbs. Poor in. One year ago: lbs. Breath Sounds: Findings: Normal Suppressed Rales Wheezing Heart: Blood Pressure: Pulse: Sounds: Murmurs: Findings: Normal Abnormal Other significant physical abnormalities: Signature Address Date BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.USCourtForms.com
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