Doctors Report Of MMI-Permanent Partial Impairment {C-4.3}

C-4.3 - DOCTOR'S REPORT OF MMI/PERMANENT PARTIAL IMPAIRMENT. Use this form: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment. Submit Form C-4.3 attached to electronically submitted CMS-1500 medical bill as the medical narrative. Do not send the form separately to the Board. Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if they have one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the patient, create the necessity for testimony, and jeopardize your Board authorization www.FormsWorkflow.com