Fill and Sign the Medical Report Occupational Disease Kentucky Form

October 2016 Edition Filed: FORM 108 - OD Medical Report – Occupational Disease 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. Purpose of examination: Treatment Evaluation requested by University Evaluation 7. Prior examination(s) by this physician (if any) and date(s): B. PLAINTIFF/EMPLOYEE HISTORY Plaintiff/employee related history of complaints or allegedly due to an occupational disease as follows: Note: If the occupational disease is lung or heart-related, include plaintiff/employee’s smoking history. C. EMPLOYMENT HISTORY Employment History (Form 104) dated was reviewed with plaintiff/employee for accuracy and pertinent employment history is listed. If no 104 was reviewed, state the history received from plaintiff/employee. D. TREATMENT – Prior and Current Based upon a review of records and/or history related by plaintiff/employee, treatment (including any periods of hospitalization) provided for the above complaints has been as follows: (list medical records reviewed) E. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings related to the occupational disease. If the occupational disease is lung or heart-related, include all findings pertinent to the respiratory and cardiovascular systems. F. DIAGNOSTIC TESTING Include any testing reviewed and relied upon for medical conclusions. This will include X-rays, CT scans, MRI, Chest x-ray – Use ILO Classification and attach ILO Form if alleging a pneumoconiosis, Other x-rays reviewed of plaintiff/employee and dates (use ILO Classification and attach ILO Form if alleging pneumoconiosis), Pulmonary function testing pre-broncholilator, Pulmonary function testing post-bronchodilator, if indicated, or Other (please specify) Test Date Personally Reviewed Summary of Results F. DIAGNOSTIC TESTING, Cont. Test Date Personally Reviewed Summary of Results G. DIAGNOSIS H . IMPAIRMENT 1. Using the Edition of the AMA Guides to the Evaluation of Permanent Impairment, the Plaintiff/Employee’s permanent whole body functional impairment is %. If the impairment is due to Loss of pulmonary function, give class and percentage. 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. I. CAUSATION 1. Within reasonable medical probability, is plaintiff/employee’s disease or condition causally related to his/her work environment? ☐ Yes ☐ No 2. Within reasonable medical probability, is any pulmonary impairment caused in part by factors in plaintiff Plaintiff/employee’s work environment (e.g., coal dust, chemicals)? ☐ Yes ☐ No If yes, explain: 3. Identify the relevant factors in the work environment and explain the causal relationship between the factors in the work environment and the above diagnosis. J. 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? K. RECOMMENDATIONS FOR TREATMENT 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 108-OD 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, Depart m ent of W orkers Clai m s, 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 chapter, 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. Height of a patient should be m easured in centi m eters and without shoes. If the patient’s height is an odd nu m ber of centi m eters, the next highest even height in centi m eters shall be used. 5. Objective m edical findings to support a m edical diagnosis m eans infor m ation gained through direct observation and testing of the patients, applying objective or standardized m ethods. KRS 342.0011(33). 6. 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). 7. Any person w ho kno w ingly and w i th 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.