Fill and Sign the California Workers Compensation Application Form

Change in treatment plan Discharged Periodic Report (required 45 days after last report) Change in work statusChange in patients condition Need for referral or consultation Need for surgery or hospitalization Info requested by Other Last                         Address                         Date of Injury       Date of Birth       Occupation                   Name       Claim Number       Address                         Phone       FAX       Employer name:       Employer Phone                   1.       2.       3.                               Remain off work until Return to modified work on                  Return to full duty on       Date of exam:       Cal. Lic. #       Executed at:       Date:       Name:       Specialty:       Phone:       Address:      Next report due no later than       State of California Additional pages attached Division of Workers' CompensationPRIMARY TREATING PHYSICIAN'S PROGRESS REPORT (PR-2) Check the box(es) which indicate why you are submitting a report at this time. If the patient is ''Permanent and Stationary'' (i e has reached maximum medical improvement) do not use this form. You may use DWC Form PR-3 or IMC Form 81 556 Patient: First M.I . Sex Cit y State Zip SS# Phone Claims Administrator: City State Zip The information below must be provided. You may use this form or you may substitute or append a narrative report. Subjective complaints: Objective findings: (Include significant physical examination, laboratory, imaging, or other diagnostic findings.) Diagnoses: ICD-9 ICD-9 ICD-9 Treatment Plan: (Include treatment rendered to date. List methods, frequency and duration of planned treatment(s). Specify consultation/referral, surgery, and hospitalization. Identify each physician and non-physician provider. Specify type, frequency and duration of physical medicine services (e.g., physical therapy, manipulation, acupuncture). Use of CPT codes is encouraged. Have there been any changes in treatment plan? If so, why? Work Status: This patient has been instructed to: with the following limitations or restrictions (List all specific restrictions re: standing, sitting, bending, use of hands, etc. } with no limitations or restrictions Primary Treating Physician: (original signature, do not stamp) I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code § 139.3. Signature: DWC Form PR-2 (Rev. 1/1/01) (Use additional pages, if necessary)