What if the report has a wrong patient name?

Correct the error in a new report or by using an addendum. Include a clear note explaining the correction and the clinician's signature and date to preserve the chain of record.

Can the report be signed electronically?

Yes. Electronic signatures meet ESIGN and UETA standards when intent, consent, attribution, and retention are documented; ensure HIPAA protections and a BAA if PHI is handled.

Is notarization required?

Not typically required for clinical reports, but some state or payer programs may request notarized attestations. Check payer and state-specific submission rules before notarizing.

How do I submit supporting records?

Attach relevant imaging, labs, and prior notes as PDF attachments. Label files clearly and reference attachments in the body of the report for efficient review.

What authentication level should I use?

Use email verification for routine reports; require stronger authentication (SMS code or multi-factor) when payer or program rules demand higher assurance or when PHI exposure is significant.

How do I correct a signed report?

Issue an addendum or corrected report dated and signed by the clinician. Note the reason for correction and keep both original and corrected versions for audit and legal purposes.

Electronic Signature
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Primary Treating Physician Report

Primary Treating Physician Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

REQUEST FOR SUMMARY RATING DETERMINATION
of Primary Treating Physician Report

State of California

Division of Workers' Compensation

Disability Evaluation Unit

To be used for injuries which occur on or after January 1, 1994.

INSTRUCTIONS:

Complete this form and send it to the Disability Evaluation Unit along with a copy of the primary treating physician's report.
This form and any attachments including a copy of the primary treating physician's report must be served on the other party.
If you receive the completed form from the other party and you disagree with the description of the occupation or earnings, please attach the correct information to a copy of this form and send it to the Disability Evaluation Unit. You must also send a copy of your objection to the other party.

REQUEST IS MADE BY:

Employee Claims Administrator

PHYSICIAN

EXAM DATE

Claims Administrator Information (if known and if applicable)

Name (Please leave blank spaces between numbers, names or words)

Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)

Street Address 2/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Claim No.

Phone Number

Adjustor

Employee Information

Mr. Ms. Mrs.

First Name

MI

Last Name

Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)

Street Address 2/PO Box (Please leave blank spaces between numbers, names or words)

International Address (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Date of Injury

Date of Birth

SSN (Numbers Only)

Case No.

Employer

Nature of Employers Business

Job Title

DESCRIBE THE GENERAL DUTIES OF THE JOB (Attach job description or job analysis, if available):

WEEKLY GROSS EARNINGS: $

Attach a wage statement/DLSR 5020 if earnings are less than maximum. Include the value of additional advantages provided such as meals, lodging, etc. If earnings are irregular or for less than 30 hours per week, include a detailed description of all earnings of the employee from all sources, including other employers, for one year prior to the date of injury. Benefits will be calculated at MAXIMUM RATE unless a complete and detailed statement of earnings is received.

PROOF OF SERVICE BY MAIL

On , I served a copy of this Request for Summary Rating Determination on

Name of Employee

Address

City

State

Zip Code

by placing a true copy enclosed in a sealed envelope with postage fully prepaid, and deposited in the U.S. Mail. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Signature

DWC-AD form102 (DEU) (11/2008)

DEU102

What the Primary Treating Physician Report Is

The Primary Treating Physician Report documents a patient's diagnosis, treatment plan, functional limitations, and expected recovery timeline as recorded by the treating clinician. It is commonly used in workers' compensation, disability claims, and insurance evaluations to establish medical causation, work capacity, and continuing care needs. The report typically summarizes medical history, objective findings, tests, procedures performed, medications, and recommended work restrictions or accommodations. Recipients use it to authorize benefits, approve modified duty, or determine compensability. Accuracy and timely delivery affect claim outcomes and care coordination between clinical providers, payers, and employers.

Why a Clear Report Matters

A clear Primary Treating Physician Report speeds benefit decisions, reduces disputes over medical facts, and guides safe return-to-work planning. It provides documented medical rationale for work restrictions and treatment authorizations, improving coordination among clinicians, insurers, and employers while preserving legal record integrity.

Who Typically Completes and Uses This Report

Typical users include treating clinicians, claims examiners, occupational health staff, and employer case managers who rely on clinical findings.

Treating clinician — completes the report to document diagnosis, treatment, and functional status.
Claims examiner — uses findings to determine benefits, work restrictions, and medical necessity.
Employer/HR — reviews restrictions for modified duty and workplace accommodations promptly.

Step-by-Step: Completing the Report

Follow these core steps when preparing a Primary Treating Physician Report to ensure clarity, completeness, and timely delivery to claims staff.

01

Prepare Record: Collect medical history, test results, and prior reports before drafting.
02

Document Findings: Record objective exam findings, diagnostics, and current diagnosis.
03

State Restrictions: Specify work restrictions, durations, and functional limitations clearly.
04

Sign & Date: Include clinician signature, license number, and service date.

Configuring an Online Report Workflow

Set up a reusable online workflow to standardize collection, require essential fields, and route signed reports to claims and employer systems.

Field	Configuration
Template	Use a reusable template with locked required fields.
Routing	Auto-route final PDF to claims, employer, and patient portals.
Authentication	Require signer authentication: email plus SMS code when needed.
Retention	Store signed copies in secure archive for required retention period.

How Electronic Submission Typically Flows

A typical eSubmission workflow moves the completed report from clinician to payer and employer with authentication, tracking, and an auditable record.

Upload Record: Attach exam notes, imaging, and lab reports.
Place Fields: Mark signature, date, and restriction fields for completion.
Authenticate Signer: Use email verification, SMS code, or stronger methods when required.
Send & Track: Deliver to recipients and capture an audit trail for the record.

Technical Requirements for Digital Filing

Digital submission requires a secure eSignature platform that supports HIPAA compliance, audit trails, and PDF or DOCX import.

File Types: PDF, DOCX, and structured forms.
Integrations: EHR, claims systems, and cloud storage.
Authentication: Email, SMS code, or KBA.

Timelines and Submission Expectations

Timelines vary by payer and jurisdiction; submit Primary Treating Physician Reports promptly to avoid benefit delays or claim disputes.

Initial Submission Deadline:

Submit promptly; many payers request within 14–30 days of the visit.

Updated Reports:

Send updates when condition changes or typically every 30–90 days during ongoing care.

Urgent Findings:

Communicate urgent findings by phone and follow with the written report same day.

Record Retention:

Retain copies per policy; healthcare records are often retained six years.

Appeals and Revisions:

Submit corrections or peer reviews within payer-specific appeal timelines to preserve rights.

Common Errors to Avoid When Preparing the Report

Incomplete medical history or missing prior test results that reduce clarity and delay claim decisions.
Lack of objective findings or quantifiable measures, creating ambiguity about functional capacity and work restrictions.
Handwritten, illegible, or unsigned reports that impede verification and may be rejected by payers.
Delayed transmission to the payer or claims system, increasing risk of benefit interruptions or administrative denials.

Practical Risks of an Incorrect or Late Report

Claim Denial: Delayed benefits

Treatment Delay: Interrupted care

Appeal Exposure: Administrative burden

Legal Risk: Evidentiary challenges

Billing Rejections: Claim coding errors

Privacy Violations: HIPAA compliance gaps

Required Data Elements and Security Considerations

Patient ID: Full name, DOB

Visit Date: MM/DD/YYYY

Clinical Findings: Diagnosis, exam

Functional Limits: Restrictions, duration

Clinician Info: Name, license, NPI

Data Security: TLS 1.2/1.3; AES-256

eSignature Pricing and Feature Comparison for Report Workflows

Compare base pricing, basic features, and common compliance attributes across providers commonly used to sign and submit healthcare-related reports.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA required)	Yes	Yes	No	No

FAQs and Troubleshooting

Common questions about completing, signing, and submitting a Primary Treating Physician Report, and practical steps to resolve them.

Need help? Contact support

What if the report has a wrong patient name?
Correct the error in a new report or by using an addendum. Include a clear note explaining the correction and the clinician's signature and date to preserve the chain of record.
Can the report be signed electronically?
Yes. Electronic signatures meet ESIGN and UETA standards when intent, consent, attribution, and retention are documented; ensure HIPAA protections and a BAA if PHI is handled.
Is notarization required?
Not typically required for clinical reports, but some state or payer programs may request notarized attestations. Check payer and state-specific submission rules before notarizing.
How do I submit supporting records?
Attach relevant imaging, labs, and prior notes as PDF attachments. Label files clearly and reference attachments in the body of the report for efficient review.
What authentication level should I use?
Use email verification for routine reports; require stronger authentication (SMS code or multi-factor) when payer or program rules demand higher assurance or when PHI exposure is significant.
How do I correct a signed report?
Issue an addendum or corrected report dated and signed by the clinician. Note the reason for correction and keep both original and corrected versions for audit and legal purposes.

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Primary Treating Physician Report

REQUEST FOR SUMMARY RATING DETERMINATIONof Primary Treating Physician Report

Employee Information

PROOF OF SERVICE BY MAIL

What the Primary Treating Physician Report Is

Why a Clear Report Matters

Who Typically Completes and Uses This Report

Step-by-Step: Completing the Report

Configuring an Online Report Workflow

How Electronic Submission Typically Flows

Technical Requirements for Digital Filing

Timelines and Submission Expectations

Initial Submission Deadline:

Updated Reports:

Urgent Findings:

Record Retention:

Appeals and Revisions:

Common Errors to Avoid When Preparing the Report

Practical Risks of an Incorrect or Late Report

Required Data Elements and Security Considerations

eSignature Pricing and Feature Comparison for Report Workflows

FAQs and Troubleshooting

Explore Templates

REQUEST FOR SUMMARY RATING DETERMINATION
of Primary Treating Physician Report