Fill and Sign the Attending Physicians Report Form 6virginia Workers

Attending Physician's Report Virginia Workers' Compensation Commission 1000 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. Employee 2. Phone number 1. Patient's name 4. Date of birth 5. Sex 3. Address Male Female 6. Social security number Background Information 7.Name of employer 8. Address of employer 9.Date of injury or illness 10. Patient's account of how injury or exposure to occupational disease occurred 11. Date of first visit 13. Person authorizing treatment. 12 Date of discharge Findings and Diagnosis 14 Findings upon examination, including results of x-rays, laboratory studies, etc. Please note any prior injuries and pre-existing conditions. Provide additional comments on the reverse side of this form. 19. Provide names and addresses of other health care Providers to whom patient was referred 21. Please describe ,20. Was there any fracture or amputation? ifyes Yes No Unknown Was there disability for work'' 23. Date disability began 24. Date able to return to light work 25. Date able to return to regular work if 27 Please describe 28. Has patient reached maximum medical improvement? ifyes Yes No Attending Physician 29. Name of attending physician 30. Address 31 Date of this report I certify that I personally examined and treated this patient Signature M D Attending Physician's Report This report is required by the Virginia Workers' Compensation Act Reserved VWC file number The boxes Insurer code Insurer location to the right are for the Insurer claim number use of the Insurer yes Yes No Unknown Yes No Unknown 15. Diagnosis 16. Is diagnosis condition due tothe occurrence described bythe patient? Yes No Unknown 17. Nature of treatment 18. Dates of your treatment INSTRUCTIONS Attending Physician's Report VWC Form No. 6 Complete all parts of this form noting all injuries, no matter how minor. Type or using this side of the form for any additional print all information in black comments. Be sure to sign the form at the bottom. Submit the report to the employer or to the employer's insurance carrier Remarks