Fill and Sign the M1 Workers Comp Form pdfFiller

M-1 DIAGNOSTIC MEDICAL REPORT MAINE WORKERS' COMPENSATION BOARD EMPLOYEE NAME: EMPLOYEE SSN (last 4 digits only): XXX -XX - EMPLOYEE DOB: EMPLOYEE PHONE: EMPLOYER NAME: EMPLOYER ADDRESS: DATE OF INJURY: TIME OF INJURY: AM PM DID INJURY OCCUR ON EMPLOYER PREMISES? YES NO IF NO, LIST PLACE OF INJURY SUPERVISOR’S NAME SUPERVISOR’S PHONE: EMPLOYER FAX: NATURE/CAUSE OF INJURY : DATE OF THIS EXAMINATION : _______________________________ _________ INITIAL PROGRESS FINAL ICD -9/ 10 DIAGNOSIS CODES :_________________________________________ ____________________________________________________________ IN MY OPINION, THESE DIAGNOS ES ARE WORK RELATED NOT WORK RELATED NOT YET IDENTIFIED AS TO CAUSE HAVE DIAGNOSTIC TESTS BEEN PE RFORMED? YES NO , IF YES, LIST: ________________________________ ________________________ IS TREATMENT TO CONTINUE ? YES, IF YES, DATE TO BE SEEN AGAIN:________ __________ NO , IF NO , PATIENT AT MMI ? YES NO ESTIMATED LENGTH OF TREATMENT ________________________________ TREATMENT PLAN : __________________________________________________________________________________________________ _________ _____________________________________________________________________________________________________________________________ OFFICE PROCEDURES: _________________________________________________________________________________________________ _______ MEDICAL REFERRAL SPECIALTY: ___________________________________________CONSULTANT: _______________________________________ DOES TREATMENT INCLUDE MEDICATION THAT PREVENTS PATIENT FR OM DRIVING OR PERFORMING SAFETY SENSI TIVE WORK ? YES NO IF YES, LIST ALL MEDICATIONS: ____________________________________________________________________________________________________ WORK CAPACITY : REGULAR DUTY NO WORK CAPACITY - IF CHECKED, ESTIMATED DATE OF RETURN : _________ ___________________ MODIFIED WOR K (DESCRIBE RESTRICTIONS BELOW OR ON REVERSE ) IF CHECKED, ESTIMAT ED LENGTH OF RESTRICTIONS? ________________________ BODY REGION (S) THAT RESTRICTIONS APPLY TO: _____________________________________________________________________________________ RESTRICTIONS RECOMMENDED *: List Below OR See side 2 of form for detailed restrictions *Restrictions are provided at the professional recommendation of the medical provider. Actual functional testing may not have been performed to validate employee’s ability . ___________________________________________________________________________________________ ______________________________________________________________ SIGNATURE OF HEALTH CARE PROVIDER DATE PRINT NAME ____________________________ ADDRESS _______________________________________ TELEPHONE _______ __________________ M- 1 ( Effective 9/1/18) GUIDELINES FOR COMPLETING THE M1 FORM ESTIMATED LENGTH OF TREATMENT : describe in days, weeks, or months TREATMENT PLAN : INCLUDE items like REST, MEDICATION, EXERCISE, or other forms of treatm ent OFFICE PROCEDURES : INCLUDE Items like CAST, SPLINT, STRAPPING, INJECTIONS, SUTURES, etc. MEDICAL REFERRALS : INCLUDE items like THERAPY, SURGEON, CHIROPRACTIC, etc. MODIFIED WORK : INDICATE RIGHT or LEFT as appropriate; FREQUENCY (Never, Occasional