Worker's Compensation

Medical Report Information Required

1. Patient information
2. History & diagnosis
3. End of Healing (or Maximum Medical Improvement) information
4. Permanent disability information (stated below are some additional requirements):
   
   1. Finger injuries
   • Complete both sides of the medical report
   • Submit comparative x-rays for all amputations beyond the distal joint
   • Dominant hand identification is needed when an amputation is greater than 2/3 of the distal joint
   2. Eye injuries
   • Complete form WKC-16A
   3. Knee injuries
   • If surgery was performed, need type & number of procedure(s)
   • Copy of all operative reports should be submitted
   4. Back injuries
   • If surgery was performed, state type & number of procedure(s) and number of spinal levels involved
   • Copy of all operative reports should be submitted
   • Prior disability & prognosis
   • Physician /Chiropractor signature