Free Microsoft Word - WorkersCompensationMedicalStatusQuestionnaire.DOC - North Carolina

Workers' Compensation Medical Status Questionnaire
Instructions
· The attached questionnaire, which has been approved by the North Carolina Industrial Commission, may be submitted by an employer/insurer paying compensation for an admitted workers' compensation claim to medical providers who have treated an employee for a work-related injury or condition. Medical providers are authorized by N.C. Gen. Stat. Sec. 97-25.6 to respond to these questions without an authorization from the employee. The medical provider may respond in any of the following ways: 1. By providing appropriate responses on the attached questionnaire; 2. By including appropriate responses in the medical notes; or 3. By including appropriate responses in a letter. · · · · Medical providers need only respond to questions that are checked by the employer on the attached questionnaire. Medical providers are not required to answer questions for which they do not have sufficient information to formulate an opinion. Medical providers may charge, and the requesting employer/insurer shall pay, a reasonable fee not to exceed the current fee established under the NCIC fee schedule for CPT code 99080. Responses shall be provided to the employer or its insurer (or their designated agents or representatives, including the assigned rehabilitation professional), and to the employee or his/her representative simultaneously.

· ·

Medical Provider Work or Job Status Forms
o Medical providers may continue the practice of providing Work or Job Status Forms to the employee and the employer/insurer or assigned rehabilitation professional after each visit or when appropriate. This may be done without the express authorization of the employee.

Workers' Compensation Medical Status Questionnaire
Patient name:___________________________________ Patient ID #:____________________________________ Employer:______________________________________ Treating physician:_______________________________ Today's date:_______________________________ Date of injury:_______________________________ Carrier:____________________________________ IC file:_____________________________________

Please answer ONLY the checked questions.
_____ 1. _____ 2. Diagnosis/diagnoses:____________________________________________________________________ _____________________________________________________________________________________ In your opinion, did the job duties or work place incident, as described by the patient, more likely than not (please check the one that, in your opinion, best applies): _____ Have/has no relation to the current injury or condition; _____ Cause or significantly contribute to the injury or condition; _____ Aggravate, accelerate, or activate a preexisting condition; or _____ Combine with other non-work related factors to bring about the current injury or condition. Other medical conditions that are affected/exacerbated by the injury or condition:____________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Reasonable and necessary treatment/treatment plan (to include: labs, medications, diagnostic images, tests, studies, referrals, physical therapy, etc.): ____________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________ Prescribed medications for the injury or condition that would impair ability or judgment needed to perform certain jobs:___________________________________________________________________________ _____________________________________________________________________________________ At this time, given the patient's injury or condition, is the patient able to return to his/her job as provided in the attached job description: YES; NO. If "yes," please skip to question #9. Work restricted to _________ hrs per day; _____ days per week. Anticipated time patient will be under such restrictions:_______________________________________________________________________ Restrictions due to the injury or condition (check all that apply, specify pounds and frequency as appropriate, and explain): Lifting:__________________________________ Pushing/pulling____________________________ Bending/stooping:_________________________ Kneeling; squatting:________________________ Twisting:________________________________ Use of extremities:_________________________ Standing:________________________________ Walking:_________________________________ Sitting:__________________________________ Repetitive motions:_________________________ Driving:_________________________________ Vibrations:________________________________ Climbing:________________________________ Splints/crutches/bandages:___________________ Other conditions (e.g., dry work only; no heat exposure, etc.):__________________________________ _____________________________________________________________________________________ If patient has reached maximum medical improvement (MMI), what is the permanent impairment for the injury or condition? Body part:__________________; Percentage:_________%; MMI not reached______ Body part:__________________; Percentage:_________%; MMI not reached______

_____ 3.

_____ 4.

_____ 5.

_____ 6. _____ 7. _____ 8.

_____ 9.

Physician signature:___________________________________________Date:_________________________