Fill and Sign the Nh Workers Compensation Form

Yes No Unclear Full Duty With Modification. If so, for what duration? Yes No Yes No UndeterminedEmployee SS # Occupation Date last worked W.C.insurer Employer Work telephone # Employer contact Employer address Initial visit Follow-up visit Date of injury Worker's statement of the incident Worker's complaints Diagnosis/Prognosis Treatment plan Continue Working Yes Date No Employee can lift/carry maximally Employee can lift/carry frequently What special accommodations are required? NEW HAMPSHIRE WORKERS' COMPENSATION MEDICAL FORMThis 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. HEALTH PROFESSIONAL TO COMPLETE Tim e In your opinion is this injury and disability as a result of injury described above? EMPLOYEE WORK CAPABILITY Can return to work: Employee can No Restrictions Frequentl y Occasionall y Unable to lbs .ben d lbs .knee l squa t clim b Employee can work a maximum of # --- hours/day, # --- days /wk.stan d wal k sit reac h driv e Othe rdo fine motor Has employee reached maximum medical improvement? N o Wris t Elbo w Shoulde r Ankl e repetitiv e Righ t Has injury caused permanent impairment? motion s Lef t 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 signature Provider's Printed name 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 75 WCA-1 (06/94) White - Insurer/Managed Care Yellow - Provider Pink - Employee/Employer