Healthcare WHFO Dynamic

Healthcare WHFO Dynamic

Patient Information

Patient Name:

Date of Birth:    Gender:

Employment & Referral

Work Status at Time of Assessment:    Date of Injury/Onset:

Insurance & Coverage

Medical History & Current Status

Functional Assessment (WHFO Dynamic)

Primary Complaint / Functional Limitation:

Lifting / Carrying Prolonged Sitting Prolonged Standing Bending / Stooping

Other limitations:

Assessment Purpose, Risks & Benefits

Purpose: The purpose of this functional assessment is to document current functional capacity, identify work-related limitations, and provide recommendations to assist in safe return to work or medical management. The assessment may inform treatment and administrative decisions by the patient, treating clinicians, employer, and payer representatives as authorized below.

Risks and Benefits: By signing, the patient acknowledges that participation in physical testing or assessment may involve transient discomfort, pain exacerbation, or fatigue. Expected benefits include an objective determination of functional abilities and tailored recommendations to reduce risk of reinjury. The patient has the right to decline any portion of the assessment.

Authorization to Use and Disclose Health Information

I authorize the release of my protected health information and assessment reports related to this WHFO Dynamic assessment to the entities I select below for the stated purpose of care coordination, workers' compensation adjudication, disability management, and return-to-work planning. This authorization includes diagnostic findings, clinical impressions, objective testing results, and billing information.

Employer Insurer / Payer Treating Provider(s) Case Manager

Expiration: This authorization expires on or upon fulfillment of the permitted disclosure unless earlier revoked in writing. Revocation will not apply to disclosures already made in reliance on this authorization.

Redisclosure: I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and no longer protected by privacy regulations. I release the provider from liability for release to authorized recipients identified in this form.

Privacy Acknowledgment

By signing below I acknowledge that I have been provided a copy of the facility's privacy practices and understand how my health information will be used and shared for treatment, payment, and healthcare operations as described in this form to the extent permitted by law.

I consent to the assessment and authorize the disclosures indicated above. I understand I may revoke this authorization in writing except to the extent that action has already been taken in reliance upon it.

Certification: I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that submission of false information may result in administrative action and may affect the disposition of claims or employment status where applicable.

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