Free WCB M-1 - Maine

M-1 REASON FOR REPORT CIRCLE ONE INITIAL PROGRESS FINAL

TYPE OF PRACTITIONER CIRCLE ONE MD DO DC LIST OTHER _____________________

PRACTITIONER'S REPORT STATE OF MAINE WORKERS' COMPENSATION BOARD Office of Medical/Rehabilitation Services
EMPLOYEE LAST NAME:

E M P L O Y E E

EMPLOYER NAME:

FIRST NAME:

M.I.:

EMPLOYER MAILING ADDRESS & PHONE #:

ADDRESS - NUMBER AND STREET:

INSURER NAME:

CITY:

STATE:

ZIP:

HOME PHONE:

INSURER MAILING ADDRESS:

DATE OF INJURY:

SSN:

PATIENT'S COMPLAINTS:

ICD-9 CODE: IN MY OPINION, THIS PROBLEM IS WORK RELATED YES NOT WORK RELATED NO RESULTS: IS NOT YET IDENTIFIED AS TO CAUSE

HAVE DIAGNOSTIC TESTS BEEN PERFORMED?

P R A C T I T I O N E R

DATE OF THIS EXAMINATION :

/

/ / /

IS TREATMENT TO CONTINUE? ESTIMATED LENGTH OF TREATMENT?

YES

NO

DATE PATIENT TO BE SEEN AGAIN: TREATMENT PLAN:

LIST ANY MEDICATION PRESCRIBED FOR THIS DIAGNOSIS/CONDITION THAT WOULD PREVENT YOUR PATIENT FROM DRIVING AND/OR WORKING SAFELY:

IF UNABLE TO WORK, ADVISE ESTIMATED DATE OF RETURN : WORK CAPACITY: RESTRICTIONS YES/NO REGULAR DUTY DESCRIBE:

/

/

P.I. RATING :

/

/

MODIFIED DUTY

NO WORK CAPACITY

IS PERMANENT IMPAIRMENT EXPECTED? HAS MMI BEEN REACHED?

YES YES

NO NO

SIGNATURE OF PRACTITIONER TELEPHONE #:
WCB M-1 (6/99) DISTRIBUTION:

PRINT NAME AND ADDRESS NARRATIVES ATTACHED? YES NO

PRACTITIONER (1) EMPLOYEE (2) EMPLOYER (3)

INSURANCE COMPANY (4)