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Physicians Roentgenographic Interpretation Report of Occupational Pneumoconiosis BI-206 - West Virginia
| Physicians Roentgenographic Interpretation Report of Occupational Pneumoconiosis Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-206 Physician's Roentgenographic Interpretation Report of Occupational Pneumoconiosis Claimant Name: Claimant's Social Security Number: 1a. Date of X-Ray (mm/dd/yyyy) Type of Reading: A 1b. Film Quality 1 2 3 U/R Yes (Complete 2b and 2c) b. Zones B P If not grade L give reason: Claim Number: 01/06 Please return completed form to: BrickStreet Mutual Insurance Occupational Pneumoconiosis Unit P.O. Box 3151 Charleston, WV 25332-3151 Facility Identification: 1C. Is Film Completely Negative? Yes (Go to Section 5) No (Go to Section 2) 2a. Any Parenchymal Abnormalities consistent with pneumoconiosis? 2b. Small Opacities a. Shape / Size Primary P Q R S T U Secondary P Q R S T U No Proceed to Section 3 c. Profusion 0/1 1/0 2/1 3/2 0/0 1/1 2/2 3/3 0/1 1/2 2/3 3/4 Proceed to Section 3a 2c. Large Opacities Size O A B C R L 3a. Any Pleural Abnormalities consistent with pneumoconiosis? 3b. Pleural Thickening C o m p le t e i n b l u e o r b l ac k i n k. Yes (Complete 3b, 3c, 3d) No Proceed to Section 4a 3c. Pleural Thickening.....Chest Wall a. Circumscribed (plaque) L Site In Profile i. Width L ii. Extent Face On iii. Extent O 1 2 3 Site 3 3 3 a. Diagram b. Wall c. Other Sites O 1 O 2 L O O O 1 1 1 2 2 2 3 O O O R A 1 B 2 C 3 O O O L A 1 B 2 C 3 b. Diffuse Site In Profile i. Width ii. Extent Face On iii. Extent O O O O R A 1 1 B 2 2 C 3 3 O O O O L A 1 1 B 2 2 C 3 3 a. Diaphragm (plaque) Site O R b. Costophrenic Angle Site O R 3d. Pleural Calcification Site a. Diaphragm b. Wall c. Other sites 4a. Any other abnormalities? 4b. Other Symbols (obligatory) O AX BU CA CN CO OD CP CW DI EF EM ES FR HI HO ID IH KL PI PX RP TB Date personal physician notified O R O O O 1 1 1 Extent 2 2 2 Extent 3 3 3 Yes Complete 4b and 4c No Proceed to Section 5a Report items which may be of present clinical significance in this section. 4c. Other Comments: Should the worker see a personal physician because of comments in Section 4c? 5a. Film Reader's Initials Physician's Signature Physician's Social Security # Yes No Proceed to Section 5a Date of Reading Date BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.USCourtForms.com
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