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Date: October 16, 2007
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State: New Mexico
Category: Workers Compensation
Author: MDannemann
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STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION FORM LETTER TO HEALTH CARE PROVIDER Instruction to the person submitting this form to the health care provider: Along with this form, you must provide a copy of the WCA- approved medical release form that has been signed by the Worker within the last 6 months.


HEALTH CARE PROVIDER (name and address)

____________________________________________________________ ____________________________________________________________ ____________________________________________________________



WCA No.:______________________

Date of birth: _______________________________

Social Security number: _______________________

Attached is a release of medical information by the Worker/Patient. The information requested in this letter is necessary to evaluate the Worker's legal claims. By promptly completing these forms, you speed the process of evaluation, including whether medical bills should be paid by the insurance carrier. Please answer all questions which you believe to be pertinent. Your answers must be based upon a reasonable medical probability.

1. 2. 3.

Who referred Worker to you for treatment?____________________________________________ Date of Worker's most recent visit or treatment:_________________________________________ What is your diagnosis of the condition(s) for which you have treated the Worker? _______________________________________________________________________________ _______________________________________________________________________________


In your opinion, are the conditions or complaints for which you have treated the Worker causally related to an on-the-job injury? Yes___ No___

Date of injury: ______________________________________ 5. Is the Worker suffering from a disease that, in your opinion, is related to employment? Date of occurrence: ______________________________________ Form Letter to Health Care Provider Form DR-004, Rule 11.4.4. NMAC 9(R)(2)(D) version 10/07, WCA rules edition 8/31/05 page 1 Yes___ No___

6. 7.

Indicate the period of time the Worker has been unable to work: ____________________________ Is Worker able to return to work? Yes_____ If yes, same job? _____ Different job? _____ Any restrictions? __________________________________________________________________ No_____ If no, when do you anticipate a return to work?___________________________________


Has the Worker reached the date after which further recovery from, or lasting improvement to, an injury can no longer be reasonably anticipated (MMI)? Yes_____ Date of MMI: __________________________ No______ Anticipated date of MMI:


If the Worker has reached MMI, please indicate your opinion as to the percentage of the Worker's anatomical or functional abnormality existing after the date of MMI: a) b) c) d) Percentage of impairment, if any:________________________________________________ Whole body or body part:______________________________________________________ Indicate which edition of AMA Guides used:_______________________________________ AMA page numbers __________________________________________________________


Has a Physical Capacities Assessment or Functional Capacity Evaluation been performed? Yes___ No___ Was the evaluation performed by a licensed physical therapist or occupational therapist? Yes___ No___


Can the Worker: a) b) c) Lift over 50 pounds occasionally or up to 50 pounds frequently? Yes___ No___ Lift up to 50 pounds occasionally or up to 25 pounds frequently? Yes___ No___ Lift up to 20 pounds occasionally or up to ten pounds frequently, and either walk or stand to a significant degree, or sit most of the time with a degree of pushing and pulling arm or leg controls or both? Yes___ No___ d) Lift up to ten pounds occasionally or up to five pounds frequently, and occasionally walk or stand to carry out job duties? Yes ____ No___ Comments:_____________________________________________________________________

Form Letter to Health Care Provider Form DR-004, Rule 11.4.4. NMAC 9(R)(2)(D)

version 10/07, WCA rules edition 8/31/05 page 2


Please describe any other restrictions on Worker's activities not covered above: ______________________________________________________________________________________ ______________________________________________________________________________________


Other remarks:_________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________


Have you made any referrals to other health care providers, hospitals or institutions? Yes___


If yes, provide the name:__________________________________________________________________ 15. Please attach a copy of any unpaid bills. The maximum allowable fee you may charge for this form is $45.00. The fee for copying of medical records and reports for the first ten (10) pages is $10.00, and $.20 cents for each additional page.

I hereby affirm that the foregoing responses or opinions are true and correct to a reasonable medical probability.


____________________________________ Signature of Physician ____________________________________ Printed Name of Physician ____________________________________ Address ____________________________________ City/State/Zip (__________)________________________ Telephone Number

INSTRUCTIONS Physician: Give one copy of the completed form to the Worker. Send another copy of the completed form to: Clerk of the Court Workers' Compensation Administration PO Box 27198 Albuquerque, New Mexico 87125-7198

Form Letter to Health Care Provider Form DR-004, Rule 11.4.4. NMAC 9(R)(2)(D)

version 10/07, WCA rules edition 8/31/05 page 3