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
    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