Fill and Sign the Kentucky Report Injury Form

October 2016 Edition Filed: FORM 107 Medical Report – Injury/Hearing Loss, Psychological Condition KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Medical Report of DR. A. PLAINTIFF/EMPLOYEE INFORMATION 1. Plaintiff/Employee’s name: 2. Last four digits of Social Security Number/Green Card: 3. Date of Birth: 4. Plaintiff/Employee’s job title and employer: 5. Date of examination(s): 6. By whom was the examination requested: 7. Prior examination(s) by this physician (if any) and date(s): B. PLAINTIFF/EMPLOYEE HISTORY Plaintiff/employee related history of complaints or alleged injury/hearing loss/psychological condition as follows: C. TREATMENT – Prior and Current Based upon a review of records and/or history related by plaintiff/employee, treatment provided for this injury has been as follows: (Include any periods of hospitalization.) D. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings to support complaints and/or diagnosis: E. DIAGNOSTIC TESTING/Injury Include any testing reviewed and relied upon for medical conclusions. This will include X-rays, CT scans, MRIs, Myelograms, EMG/NCVs or Other (please specify) Test Date Personally Reviewed Summary of Results F. DIAGNOSTIC TESTING/ Hearing Loss Include any testing reviewed and relied upon for medical conclusions. This will include Comprehensive Audiometry, Immitance Audiometry, Otoacoustic Emissions, Communication Needs Assessments, or Other (please specify). Test Date Summary of Results G. DIAGNOSTIC TESTING/Psychological Include any testing reviewed and relied upon for medical conclusions. This will include Neuropsychological (e.g. Luria-Nebraska, Halstead-Reitan), Academic/Achievement (e.g. WRAT-R), Intellectual Capacity, Personality (e.g. MMPI, Millon, etc), Brain Imaging (MRI, CT, SPECT), or Other (please specify). Test Date Summary of Results H. SURGICAL PROCEDURE(S) Specify type and date of any surgical procedure. Include operative note if surgery performed by this physician. I. DIAGNOSIS J. CAUSATION 1. Do you believe the work event as described to you is the cause of impairment found? ☐ Yes ☐ No 2. Is any part of the impairment due to a cause other than the work event described above? ☐ Yes ☐ No 3. If yes, what is that cause and the impairment attributable to that cause? 4. If applicable, do audiograms and other testing establish a hearing loss compatable with that caused by hazardous noise exposure in the workplace? ☐ Yes ☐ No 5. If applicable, within reasonable medical probability, is plaintiff/employee’s hearing loss related to repetitive exposure to hazardous noise over an extended period of employment? ☐ Yes ☐ No 6. If applicable, within reasonable medical/psychological probability, is plaintiff/employee’s psychological condition the direct result of the physical work-related injury? ☐ Yes ☐ No K . IMPAIRMENT 1. Using the Edition of the AMA Guides to the Evaluation of Permanent Impairment, the Plaintiff/Employee’s permanent whole person impairment is %. 2. Chapters, Tables and Pages utilized to arrive at impairment rating for injuries: Body Part or System Chapter Number Table Number Page Number % Impairment of the Whole Person a. b. c. 3. Plaintiff/Employee had an active impairment prior to this injury. ☐ Yes ☐ No A. If yes, specify condition producing active impairment. B. If yes, specify percentage of impairment due to the prior active condition. 4. Date on which maximum medical improvement was reached: . L. RESTRICTIONS 1. The plaintiff/employee described the physical requirements of the type of work performed at the time of injury as follows: 2. Does the plaintiff/employee retain the physical capacity to return to the type of work performed at the time of Injury? ☐ Yes ☐ No If not, why? 3. Which restrictions, if any, should be placed upon plaintiff/employee’s work activities as a result of the injury? M. CERTIFICATION and QUALIFICATIONS of PHYSICIAN I hereby certify that the above information is correct and that all opinions were formulated within the realm of reasonable medical probability. A copy of my curriculum vitae is attached if I have not obtained a Department of Workers’ Claims Physician Index Number. Date Full name of Physician Department of Workers’ Claims Physician Index Number Instructions for Completion of Form 107 The m edical report for m s of the Depart m ent of W orkers’ Clai m s are designed to provide relevant m edical infor m ation to ad m i nistrative law judges to assist in deter m ining the occupational i m plications of a work- related injury or an occupational disease. Therefore, it is i m portant that each section of the for m s be carefully and fully co m pleted. 1. All infor m ation m ust be typed or neatly printed. 2. The Depart m ent of W orkers’ Clai m s m aintains a Physician Index with curricula vitae of physicians. Physicians m ay be included in the index by tendering a copy of a current curriculum vitae with a request for inclusion to: Physicians Index Clerk, Department of Workers’ Claims , 657 Cha m berlin Avenue, Frankfort, Kentucky 40601. 3. The AMA Guides to the Evaluation of Per m anent I m pair m ent is m andated by statute. Prior to the co m pletion of the For m , the Physician should beco m e fa m iliar with the edition currently directed by statute and regulation to be used. Reference should be m ade to chapters, page nu m bers, and tables for all physical injuries. For psychiatric conditions, the class of i m pair m ent should be stated, with reference to i m pair m ent ratings provided in prior editions. 4. Objective m edical findings to support a m edical diagnosis m eans infor m ation gained through direct observation and testing of the plaintiff/e m ployee, applying objective or standardized m ethods. KRS 342.0011(33). 5. Medical opinions m ust be founded on reasonable m edical probability, not on m ere possibility or speculation. Young v. Davidson, Ky., 463 S. W .2d 924 (1971). 6. Any person w ho kno w ingly and w ith intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, w hich is a crime.