Free untitled - Pennsylvania

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383

Social Security Number: ________ - _______ - _________

IMPAIRMENT RATING DETERMINATION FACE SHEET

Date of Injury: ______/______/____________
MM DD YYYY

PA BWC Claim Number: ____________________________
(IF
KNOWN)

Employee
First Name _________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County __________________________________________ State Telephone (_______) _______ - _______________ Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________

Employer
Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County ____________________________________________ Telephone (_______)_______-____________________________ FEIN _____________________ State Zip Code ________________________________________________ _________ ____________-_________

Insurer or Third Party Administrator (if self-insured)
Name

767 0506
DATE OF THIS NOTICE:
______/______/___________
MM DD YYYY

_________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ County ____________________________________________ Claim Number ____________________________________________ FEIN _____________________ State Zip Code Bureau Code _____________________ ________________________________________________ _________ ____________-_________

Attorney for Employee (if known)
Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ PA Attorney ID Number ________________________________

Attorney for Insurer/Employer (if known)
Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ PA Attorney ID Number ________________________________

Claim Representative SEE IMPORTANT INFORMATION ON REVERSE.
First Name _________________________________ Telephone (_______) _______ - _______________ Last Name _____________________________________________

(OVER)
LIBC-767 REV 5-06 (Page 1)

I examined the referenced employee, ________________________________________________________, with regard to establishing an Impairment Rating Determination to define the degree of impairment due to the compensable injury, if any, in accordance with the provision of Section 306(a.2) of the Pennsylvania Workers' Compensation Act. Attached is the Report of Medical Evaluation prepared as utilized by the most recent edition of the American Medical Association Guides to the Evaluation of Permanent Impairment. The original of this face sheet and report is being provided to the Bureau of Workers' Compensation, 1171 S. Cameron Street, Room 103, Harrisburg, PA 17104-2501, with copies to the employee, the employee's attorney (if known) and the insurer within 30 days of the date of the impairment evaluation. Name of Patient: _________________________________________________________ Social Security Number: ______-_____-__________ Reported Date of Injury: ______/______/___________
MM DD YYYY

Date of this Examination:

______/______/___________
MM DD YYYY

Percentage of Impairment Rating: _________% My charge of $_________________ will be billed to the Insurer or Third Party Administrator (if self-insured) for conducting this examination. I attest that I am a physician licensed in the Commonwealth of Pennsylvania and certified by an American Board of Medical Specialties approved board or its osteopathic equivalent, and that I have an active clinical practice of at least twenty (20) hours per week.

Physician
First Name _________________________________ Signature _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ State Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________

Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.

Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-767 REV 5-06 (Page 2)