Physician
Reports/Worksheets/Disclosure |
|
Form |
Description |
|
Physician's
Reports
Form
#WC164
|
This form is used by the physician to provide
information on the status, progress and medical treatment of the injured
worker. It is also used to provide information on the date of
maximum medical improvement and permanent impairment. A copy of the
completed report is provided to both the insurer and the claimant. |
|
Permanent
Mental Impairment Rating Worksheet
Form # WC-M3 Psych
|
This worksheet is
used by Level II Accredited Physicians to assign permanent mental
impairment ratings. |
|
Pharmacy
Billing Statement
Form # WC-M4 Psych
|
This form is used by the Pharmacy to bill the
carrier for payment.
|
|
Designated Health Care Provider Disclosure Form
Form #WC030
|
This form is used by a designated health care provider when a
request is made for information on ownership interests and
employment relationships. |
