Fill and Sign the Lab 500 New Hampshire Workers Compensation Medical Form

NEW HAMPSHIRE WORKERS' COMPENSATION MEDICAL FORM This form must be completed at each health professional visit (MD, DO, DC or DDS) and must be filed with the worker's compensation insurance carrier within 10 days of the treatment (first aid excluded). Failure to comply and complete this form shall result in the provider not being reimbursed for services rendered and may result in a civil penalty of up to $2,500. In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary alternative/transitional work opportunities to all employees temporarily disabled by a work related injury or illness. Employee Employer SS # Work telephone # Occupation Employer contact Date last worked Employer address W.C.insurer HEALTH PROFESSIONAL TO COMPLETE Follow-up visit Initial visit Time Date of injury Worker's statement of the incident Worker's complaints Diagnosis/Prognosis Treatment plan Yes No Unclear In your opinion is this injury and disability as a result of injury described above? EMPLOYEE WORK CAPABILITY Can return to work: Yes Date No Continue Working With Modification. If so, for what duration? Full Duty No Restrictions Unable to Employee can Frequently Occasionally lbs. Employee can lift/carry maximally bend lbs. Employee can lift/carry frequently kneel squat climb Employee can work a maximum of # --- hours/day, # --- days /wk. stand What special accommodations are required? walk sit reach drive Other do fine motor Has employee reached maximum medical improvement? No Wrist Elbow Shoulder Ankle Yes No repetitive Right Has injury caused permanent impairment? motions Left Yes No Undetermined ALL MEDICAL NOTES MUST BE ATTACHED TO BILL I certify that the narrative descriptions of the principal and secondary diagnosis and the major procedures performed are accurate and complete to the best of my knowledge. Provider's Printed name Provider's signature Provider's telephone # Federal ID# Date of visit MEDICAL AUTHORIZATION: The act of the worker in applying for workers' compensation benefits constitutes authorization to any physician, hospital,chiropractor, or other medical vendor to supply all relevant medical information regarding the worker's occupational injury or illness to the insurer,the worker's employer, the worker's representative, and the department. Medical information relevant to a claim includes a past history of complaints of, or treatment of, a condition similar to that presented in the claim. [281-A:23 V(a)] Yellow - Provider White - Insurer/Managed Care Pink - Employee/Employer 75 WCA-1 (06/94)