Capability Assessment {SFN 58550}

CAPABILITY ASSESSMENT CLAIMS DIVISION SFN 58550 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY (hearing impaired) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www.workforcesafety.com Please type or print using black or blue ink. Return the completed and signed form to WSI immediately. SECTION 1 General information - completion of this section is required Claim number Employee (First name) (Last name) Social Security number* Date of birth Employee (Street address, PO Box number) City State ZIP Code Employee Date of injury SECTION 2 Medical assessment Diagnosis code/ICD - 10 code Date of visit Body part(s) injured Purpose of visit Initial evaluation Re - check Discharge Before this injury, did the employee have any problems, injuries, or treatment to the injured body part? Yes No Injured employee is released to work with No restrictions T he restrictions indicated in Section 3 SECTION 3 capabilities restrictions ordered are in effect for home and/or work activity Physical capabilities (Related to work injury) Release of information I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medical provider or facility, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including all prior records as well as those pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding m y injury, including request for conclusions and opinions not otherwise contained within existing medical records. y 20 U.S.S 21 Se c. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulations. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of resolving claims against third parties. I authorize the release of any medical information related to my claim to my employer. Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fine s, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured employees , employers, medical providers, and attorneys. www.FormsWorkflow.com