Providers Report

PROVIDER'S REPORT OF PHYSICAL ABILITY. This form is for workers' compensation administration and used by healthcare providers to report on a worker's physical ability following an injury. The form includes sections for general information such as worker details, visit type, diagnosis, and maximum medical improvement indications. It also covers work status recommendations, including options for releasing the worker to regular work, no work at all, or modified duty, along with activity restrictions if applicable. Additionally, there is a section for follow-up services and referrals. The back page provides helpful guidelines and definitions for completing the form accurately. Based on a reasonable medical probability, you as the primary treating HCP are encouraged to fill this form out at each appointment, however you can only be reimbursed if the form is completed at the initial assessment or if there is a change in work status or activity restrictions, as indicated in the WCA Health Care Provider fee Schedule and Billing Instructions (HCP Fee Schedule). Provide a copy to the worker immediately after each office visit. Note: This form is not intended to substitute a Functional Capacity Evaluation (FCE). www.FormsWorkFlow.com