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Worker's Compensation
Medical Report Information Required
- Patient information
- History & diagnosis
- End of Healing (or Maximum Medical
Improvement) information
- Permanent disability information
(stated below are some additional requirements)
- 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
- If surgery was performed, need
type & number of procedure(s)
- Copy of all operative reports
should be submitted
- 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