Wisconsin > Workers Comp
Practitioners Report On Accident Or Industrial Disease In Lieu Of Testimony WKC-16B - Wisconsin
| Practitioners Report On Accident Or Industrial Disease In Lieu Of Testimony Form. This is a Wisconsin form and can be used in Workers Comp . |
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PRACTITIONER'S REPORT ON ACCIDENT OR INDUSTRIAL DISEASE IN LIEU OF TESTIMONY Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov FILED ON BEHALF OF: EMPLOYEE EMPLOYER OR INSURANCE CARRIER Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. 1. WC Claim Number Employee Social Security Number 2. Employer Name Employer Address Employee Name Employee Address 3. Date of Traumatic Event Worker's Compensation Insurance Carrier 4. Describe the accidental event or work exposure to which the patient attributes his/her condition. (A copy of medical history or notes containing this information will suffice if complete.) 5. Give a complete description of physical or mental disability and diagnosis. (A copy of the medical history or notes containing this information will suffice if complete and limited to the work injury.) 6. Did you treat the patient? If so, between what dates? 7. Date of last examination or evaluation 8. Date disability from work began Yes No 9. Date injured was or will be able to return to a limited type of work: State any temporary limitations. 10. Date injured was or will be able to return to full time work subject only to permanent limitations: State any permanent limitations. 11. In your opinion, is it probable that the event in Item 4 directly caused the disability? Yes No 13. If the patient suffers from a condition caused by an appreciable period of work place exposure (from Item 4), was that exposure either the sole cause of the condition, or at least a material contributory causative factor in the condition's onset or progression? Yes No WKC-16-B (R. 10/2010) 12. If not directly, is it probable that the event described in Item 4 caused the disability by precipitation, aggravation and acceleration of a preexisting progressively deteriorating or degenerative condition beyond normal progression? Yes No If yes, give date disability from work began: American LegalNet, Inc. www.FormsWorkFlow.com 14. Has accident or industrial disease resulted in any permanent disability? Yes No 15. Estimate percentage of permanent disability to the member, eye or ear involved, or compare to permanent total disability if injury is to torso or head, caused by the accident or work exposure described in Item 4. 16. What elements constitute permanent disability (such as limitation of motion, deformity, weakness, pain, lack of endurance or components of illness, e.g., isoiconias, photo toxicity, liver disease)? If limitation of motion, describe nature and percentage of limitation of each part of each member affected. (Make estimates on voluntary, not passive motions.) If amputation, state exact point bone was amputated and whether stump is tender or hardy. 17. What is the prognosis of this disability? If guarded, please explain: 18. Do you expect that any further treatment will be necessary for this condition? Yes No If YES, explain: 19. Prior to this accident or illness, did employee have any permanent disability? Yes No If YES, explain: 20. I am a practitioner licensed in and practicing in Wisconsin. Practitioner Typed or Printed Name: CERTIFICATION I certify, subject to the penalty of fine and/or imprisonment, as provided in Sec. 943.39 of the Wisconsin Statutes, that the above report truly and correctly sets forth the history, my findings, diagnosis and opinion. Practitioner Address (Street or P.O. Box): Practitioner Address (City, State and Zip Code): Practitioner Phone Number: ( ) College: _________________________________________________ Signature of Practitioner Date Signed If not licensed and practicing in Wisconsin, state where practitioner is licensed and practicing: IMPORTANT: Section 102.17(1)(d) of the Wisconsin Statutes provides that the contents of certified medical and surgical reports presented by parties shall constitute prima facie evidence as to the matter contained therein. Reports must be filed with the department and the other parties fifteen days prior to the date of hearing to be acceptable as evidence. If not so filed, it will be necessary to produce the doctor to give oral testimony at the time of hearing. American LegalNet, Inc. www.FormsWorkFlow.com
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