Free Workers' Compensation Controlled Substance Form Return completed application to ... - West Virginia


File Size: 711.2 kB
Pages: 1
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State: West Virginia
Category: Workers Compensation
Author: STAPLESS
Word Count: 509 Words, 3,620 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wvinsurance.gov/wc/pdf/forms/Controlled_Substances_Form.pdf

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Workers' Compensation Controlled Substance Form
Return completed application to the Third-Party Administrator American M ining Claims Service PO Box 6 6 0 988 Birming ham, AL 3526 6 -0 988
Date: Claimant Name: Claim Number: Claimant SSN: Date of Injury: Vendor Number: Physician Number: Physician's Name and Address: 1. What diagnosis is responsible for the claimant's pain: 2. Body Part: 3. Is the claimant's pain: Acute Chronic

Intractable

Psychogenic

Neurogenic

4. Does the claimant have a history of drug or alcohol abuse? Yes No If yes, please explain:

5. Does the claimant have a chronic illness or disease not related to the compensable injury that could be responsible for the chronic pain? Yes No If yes, explain:

6. Are there any medical conditions not related to the compensable injury that may require further treatment? Yes No If yes, briefly explain:

7. Are there any psychological factors to consider? Yes No If yes, briefly explain: 9. Is there a detailed history of the pain phenomena? Yes

8. Was there a psychological condition prior to this injury? Yes No If yes, briefly explain: No If yes, please complete the following:

Onset: ____________ Duration: ____________ Radiation: ____________ Location: ____________ Severity: ____________ Level of pain using scale __________ (Pre Analgesia) Level of pain using scale __________ (Post Analgesia) Treatment or activities other than medications that relieve pain: 10. The following medications and/or treatment/therapies have been prescribed: NSAIDS Improved Not Improved Muscle Relaxants Improved Not Improved Steroids Improved Not Improved Opioids Improved Not Improved Physical Medicine Improved Not Improved Injections Improved Not Improved 11. Have you made an attempt to decrease the Opioid dosage? Yes No If yes, when and at what intervals?

If no, why?

12. 13.

On what objective findings do you base the need for continued Opioid therapy? Have you referred the claimant for any consultations with other healthcare providers? Yes No

14. 15. 16.

If yes, with whom? ____________________ Specialty ____________________ Recommendations____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ Have you discussed with the claimant the risks and side effects involved in long-term Opioid therapy? Yes No Do you have a signed statement from the claimant showing his/her understanding? Yes No If yes, please enclose a copy. How do you rate the claimant's potential to return to his/her preinjury employment position? Excellent Good Fair Poor Have you performed any random testing to ensure that the claimant is taking the Opioid as prescribed? Yes No What were the results? 17. Does the claimant's pain inhibit or interfere with his/her ability to perform ADL's? Yes No If yes, please describe his/her limitations:

I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware th e law, specifically ยง61-3-24G, provides for severe penalties if I knowingly certify a false report or statement, withhold material facts or statement, or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge my contractual obligations to American Mining Claims Service, the third-party administrator (TPA), and agree to release any office notes and test results immediately to American Mining Claims Service, the TPA. Comments: Physician Signature: ______________________________________________ Date: ______________________________