Physician And Chiropractor Progress Report Certification Of Disability {D-39}

PHYSICIANS AND CHIROPRACTORS Claim Number: PROGRESS REPORT Social Security Number: CERTIFICATION OF DISABILITY Patients Name: Date of Injury: Employer: Name of MCO (if applicable) Patients Job Description/Occupation: Previous Injuries/Diseases/Surgeries Contributing to the Condition: Diagnosis: Related to the Industrial Injury? Explain: Objective Medical Findings: None - Discharged Stable Yes No Ratable Yes No Generally Improved Condition Worsened Condition Same May Have Suffered a Permanent Disability Yes No Treatment Plan: No Change in Therapy PT/OT Prescribed Medication May be Used While Working Case Management PT/OT Discontinued Consultation Further Diagnostic Studies: Prescription(s) Released to FULL DUTY/No Restrictions on (Date): Certified TOTALLY TEMPORARILY DISABLED (Indicate Dates) From: To: Released to RESTRICTED/Modified Duty on (Date): From: To: Restrictions Are: Permanent Temporary No Sitting No Standing No Pulling Other: No Bending at Waist No Stooping No Lifting No Carrying No Walking Lifting Restricted to (lbs.): No Pushing No Climbing No Reaching Above Shoulders Date of Next Visit: Date of this Exam: Physician/Chiropractor Name: Physician/Chiropractor Signature: D-39 (Rev. 7/99)