Medical Provider

Forms/Desk Aids...

• Designated Health Care Provider Disclosure Form
  (PDF)  (MS Word)

• Physician’s Report of Worker’s Compensation Injury
  (PDF)  (MS Word)
   
• Impairment Rating Tips - Desk Aid #11
  (PDF)  (MS Word)

• Apportionment - Desk Aid #10 
  (PDF)  (MS Word)

• Guidelines for Prescribing Controlled Substances with Link to Sample Patient Contract

   

  • Sample Patient Contract En Español

• Functional Assessment for Chronic Pain

• Pain Diagram

• Task Force Supplement for Functional Capacity Evaluation

• Functional Capacity Evaluation and Consent Form

Impairment Rating Worksheets

• AMA Guides 3rd Edition (revised) Range of Motion worksheets (used with permission of the AMA)
   

• Lower Extremity Worksheet  (PDF)  (MS Word)
   

• Mental Impairment Rating Worksheet (WC-M3-Psych)  (PDF)  (MS Word)

• Guidelines for Assessing Elements Under the Mental Impairment Rating Worksheet "Areas of Function"

• Vision Impairment Rating Worksheet  (PDF)  (MS Word)

• Hearing Impairment Rating Worksheet  (PDF) (MS Word)

For a complete listing of all Division forms and Desk Aids, please click the "Forms and Desk Aids" link on the side menu bar.

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