Fill and Sign the Physicians Workers Compensation Form

                                               Male Female                                                                         Yes No Unknown                   Yes No Unknown       No Unknown Yes                   Yes No Unknown                               Attending Physician's Report Reserved VWC file number The boxes Virginia Workers' Compensation Commission 1000 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. to the right Insurer code Insurer location are for the use of the Insurer claim number Insurer Employee 1. Patient's name 2. Phone number 3. Address 4. Date of birth 5. Sex 6. Social security number Background Information 7. Name of employer 8. Address of employer 9.Date of injury or illness 10. Patient's account of how injury or exposure to occupational disease occurred 11. Date of first visit 12 Date of discharge 13. Person authorizing treatment. Findings and Diagnosis 14 Findings upon examination, including results of x-rays, laboratory studies, etc. Please note any prior injuries and pre-existing conditions. Provide additional comments on the reverse side of this form. 15. Diagnosis 16. Is diagnosis condition due tothe occurrence described bythe patient? 17. Nature of treatment 18. Dates of your treatment 19. Provide names and addresses of other health care Providers to whom patient was referred ,20. Was there any fracture or amputation? 21. Please describe if yes Was there disability for work'' 23. Date disability began 24. Date able to return to light work 25. Date able to return to regular work if yes 27 Please describe if 28. Has patient reached maximum medical improvement? yes Yes No Attending Physician 29. Name of attending physician 30. Address 31 Date of this report I certify that I personally examined and treated this patient Signatur e M D This report is required by the Virginia Workers' Compensation Act Attending Physician's Report             INSTRUCTIONSAttending Physician's Report VWC Form No. 6 print all information in black comments. Be sure to sign the form at the bottom. Complete all parts of this form noting all injuries, no matter how minor. Type or using this side of the form for any additional Submit the report to the employer or to the employer's insurance carrier Remark s