Free Form 4.pub - Oklahoma



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FORM 4 SEND COPIES TO 1--Injured Worker 1--Employer 1--Employer's Insurer WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 This space for Court Use only In re claim of: Full Name of Injured Employee (Claimant) Claimant's Social Security Number Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured TREATING PHYSICIAN'S REPORT AND NOTICE OF TREATMENT FILE NO. (Must be filled out) State Law requires the Treating Physician to supply the injured employee, the employer and the employer's insurer with a full examining report of injuries found at the time of the examination and proposed treatment. This report must be supplied within seven (7) days after the examination. Also, at the conclusion of the treatment, the Treating Physician sh

FORM 4 SEND COPIES TO
1--Injured Worker 1--Employer 1--Employer's Insurer

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918

This space for Court Use only

In re claim of:
Full Name of Injured Employee (Claimant) Claimant's Social Security Number Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured

TREATING PHYSICIAN'S REPORT AND NOTICE OF TREATMENT FILE NO. (Must be filled out)

State Law requires the Treating Physician to supply the injured employee, the employer and the employer's insurer with a full examining report of injuries found at the time of the examination and proposed treatment. This report must be supplied within seven (7) days after the examination. Also, at the conclusion of the treatment, the Treating Physician shall supply a full report of treatment to the employer of the injured employee. (Please type or print)
1. HISTORY OF ACCIDENT: Date and Time of Accident Occupation or job of employee

(Please type or print)
State, in the employee's own words, how the accident occurred. Were the employee's injuries causally connected to the above described accident? 2. MEDICAL HISTORY State the objective complaints of the employee. State whether previous sickness or injury contributed to the employee's present condition. Was the employee hospitalized? Other significant medical history of the employee. Age Date of birth

Describe the medical treatment rendered to date. List all other treating or consulting physicians. 3. CLINICAL EVALUATION: Describe your examination and all diagnostic tests performed. State your findings and diagnoses. Describe the medical treatment you recommend for the future. 4. EVALUATION OF TEMPORARY TOTAL DISABILITY: Date of employee's first treatment by you. State the date you released the employee as able to return to work. Has the employee been totally unable to return to work for any period? Employee was temporarily totally disabled from: Is the employee's inability to work the result of the above described accident? Were medical records reviewed?

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.

I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee Address (Number and Street) City State Zip Code Employer Insurance Carrier

Signed this ____________ day of _________________, ________
Type or Print Name of Treating Physician Signature of Treating Physician Address City State Zip Code

2/06

File Size: 54.1 kB
Pages: 1
Date: February 13, 2006
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: JLutter
Word Count: 407 Words, 2,701 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.owcc.state.ok.us/CourtForms/Current/Form%204.pdf