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Periodic Report
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Change in treatment plan
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Released from care
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Change in work status
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Need for referral or consultation
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Response to request for information
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Change in patient’s condition
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Need for surgery or hospitalization
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Request for authorization
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Other:
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Other:
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Patient:
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Last Name
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First Name
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Middle Name
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Sex
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Address
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City
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State
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Zip Code
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Date of Injury
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Date of Birth
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Occupation
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SSN
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Phone
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Claims Administrator:
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Name
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Claim
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Number
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Address
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City
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State
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Zip Code
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Phone
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Fax
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Employer name:
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Employer Phone
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Mandatory Questions
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Subjective complaints:
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Objective findings:
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Diagnoses:
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1. Diagnoses:
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ICD-9
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2. Diagnoses:
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ICD-9
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3. Diagnoses:
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ICD-9
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Treatment Plan:
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Treatment rendered to date
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Method:
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Frequency
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Duration of planned treatment(s)
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Specify consultation/referral
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Surgery
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Hospitalization
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Identify each physician and non-physician.
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Physical medicine services:
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Use of CPT codes:
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Have there been any changes in treatment plan?
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If Yes, Why?
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Work Status:
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Remain off-work until
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Remain off-work until:
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Return to modified work on
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Return to modified work on
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Return to full duty on
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Return to full duty on
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Primary Treating Physician:
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Date of exam:
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Declaration:
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Signature:
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Cal. Lic. No:
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Executed at:
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Date:
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Name:
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Specialty:
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Address:
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Phone:
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