Free Workers' Compensation Diagnosis Update Return completed application to the Third... - West Virginia

Workers' Compensation Diagnosis Update
Return completed application to the Third-Party Administrator American Mining Claims Service PO Box 660988 Birmingham, AL 35266-0988
Instructions: This form is intended for use by the physician of record to update appropriate diagnostic information. Complete claimant and physician information. List ICD9-CM codes in order of severity with corresponding descriptions. Show clinical findings upon which the diagnosis is based. Sign and date the form and mail to American Mining Claims Service, the third-party administrator. 1. Claimant Name ______________________________ 2. Claim Number ______________ 3. Social Security Number _____-____-________ 4. Date of Injury ___/___/___

5. Treating Physician Name and Address ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 7. Physician's FEIN: ___________________________________

6. ICD9-CM Diagnosis Numerical Code(s) 1. Primary: 2. Secondary: 3. Secondary: 4. Secondary: ____________ ____________ ____________ ____________

8. Diagnosis Description 1. Primary: 2. Secondary: 3. Secondary: 4. Secondary: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

9. Provide clinical findings on which current diagnosis is based and advise how the present condition relates to the compensable injury. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 10. Physician Signature _____________________________________________________________ 11. Date ____________________