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Primary Treating Physicians Permanent And Stationary Report (2005 Permanent Disability Rating Schedule) DWC-PR-4 - California
| Primary Treating Physicians Permanent And Stationary Report (2005 Permanent Disability Rating Schedule) Form. This is a California form and can be used in General Workers Comp . |
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STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4) This form is required to be used for ratings prepared pursuant to the 2005 Permanent Disability Rating Schedule and the AMA Guides to the Evaluation of Permanent Impairment (5th Ed.). It is designed to be used by the primary treating physician to report the initial evaluation of permanent impairment to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient's condition becomes permanent and stationary. This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation. Patient: Last Name______________________ Middle Initial ____ First Name ___________________Sex ____ Date of Birth _______ Address ____________________________________________City _________________________ State _____ Zip ________ Occupation ______________________________ Social Security Number _______________________ Phone No. _________ Claims Administrator/Insurer: Name ________________________________________________________________ Phone Number _________________ Address ____________________________________________City _________________________ State _____ Zip ________ Employer: Name ________________________________________________________________ Phone Number _________________ Address ____________________________________________City _________________________ State _____ Zip ________ Treating Physician: Name ________________________________________________________________ Phone Number _________________ Address ____________________________________________City _________________________ State _____ Zip ________ You must address each of the issues below. You may substitute or append a narrative report if you require additional space to adequately report on these issues. Date of Injury_____________ Last date ______________ Permanent & ______________ Date of current __________________ Date worked Date Stationary Date examination Date Description of how injury/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos): Patient's Complaints: DWC Form PR-4 (Rev. 06-05) 1 American LegalNet, Inc. www.USCourtForms.com STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4) Relevant Medical History: Objective Findings: Physical Examination: Describe all relevant findings as required by the AMA Guides, 5th Edition. Include any specific measurements indicating atrophy, range of motion, strength, etc. Include bilateral measurements - injured/uninjured - for injuries of the extremities. Diagnostic tests results (X-ray/Imaging/Laboratory/etc.) Diagnoses (List each diagnosis; ICD-9 code must be included) 1. ___________________________________________________________ 2. ___________________________________________________________ 3. ___________________________________________________________ 4. ___________________________________________________________ ICD-9 ____________________________________ ____________________________________ ____________________________________ ____________________________________ Impairment Rating: Report the whole person impairment (WPI) rating for each impairment using the AMA Guides, 5th Edition, and explain how the rating was derived. List tables used and page numbers. Impairment Explanation Impairment Explanation Impairment Explanation Impairment Explanation WPI% Table #(s). Page #(s) WPI% Table #(s). Page #(s) WPI% Table #(s). Page #(s) WPI% Table #(s). Page #(s) DWC Form PR-4 (Rev. 06-05) 2 American LegalNet, Inc. www.USCourtForms.com STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4) Pain assessment: If the burden of the worker's condition has been increased by pain-related impairment in excess of the pain component already incorporated in the WPI rating under Chapters 3-17 of the AMA Guides, 5th Edition, specify the additional whole person impairment rating (0% up to 3% WPI) attributable to such pain. For excess pain involving multiple impairments, attribute the pain in whole number increments to the appropriate impairments. The sum of all pain impairment ratings may not exceed 3% for a single injury. Apportionment: Effective April 19, 2004, apportionment of permanent disability shall be based on causation. Furthermore, any physician who prepares a report addressing permanent disability due to a claimed industrial injury is required to address the issue of causation of the permanent disability, and in order for a permanent disability report to be complete, the report must include an apportionment determination. This determination shall be made pursuant to Labor Code Sections 4663 and 4664 set forth below: Labor Code section 4663. Apportionment of permanent disability; Causation as basis; Physician's report; Apportionment determination; Disclosure by employee (a) Apportionment of permanent disability shall be based on causation. (b) Any physician who prepares a report addressing the issue of permanent disability due to a claimed industrial injury shall in that report address the issue of causation of the permanent disability. (c) In order for a physician's report to be considered complete on the issue of permanent disability, it must include an apportionment determination. A physician shall make an apportionment determination by finding what approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in the course of employment and what approximate percentage of the permanent disability was caused by other factors both before and subsequent to the industrial injury, including prior industrial injuries. If the physician is unable to include an apportionment determination in his or her report, the physician shall state the specific reasons why the physician could not make a determination of the effect of that prior condition on the permanent disability arising from the injury. The physician shall then consult with other physicians or refer the employee to another physician from whom the employee is authorized to seek treatment or evaluation in accordance with this division in order to make the final determination. (d) An employ
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