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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)
  

• 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

• Eye injuries

• Complete form WKC-16A

• Knee injuries

• If surgery was performed, need type & number of procedure(s)
• Copy of all operative reports should be submitted

• 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

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