Hearing Date: Referral Form Exam Type:
Date of Request  

Claim Rep
Adjuster Full Name:
Email:
Phone:
Fax:

Claimant Employer
Company:
Contact:
Contact Title:
Address:
City:
State:
Zip:
Email:
Fax:
Phone:

Claimant Information
First, Middle, Last Name:
Job Title:
Address:
City:
State:
Zip:
Phone:
Fax:
SSN:
DOB:
Claimant Salutation:

Claimant
Attorney

Attorney:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

Injury Information

Date of Injury:

Claim Number:
Hearing Date:
Injury Description
Allowed Conditions
Contested Conditions
Objective of Independent Medical Opinion

Choice of Specialty
Physical
Psychological
Chiropractic
Other
Specify Doctor by Name Address and Phone

Purpose of Exam
Please "x" by the topics that reflect the purpose of the exam. You may also use the "Additional Comments" area to customize purposes for your circumstances or choose specific questions that follow the comments section.
1.
Contested Claim
a. As Aggravation
2.
 Additional Allowance
a. As Aggravation
3.
MMI
4.
Necessity of Treatment
5.
Second Surgical Opinion
6.
Extent of Disability
a. Work Restrictions
b. TTD dates:
to
7.
PPD
8.
PTD
9.
Other
Additional Comments:

Optional Questions

CAUSATION QUESTIONS

Please mark the questions you would like the consultant to address.
  1. Based on the current objective findings, documented objective findings, and mechanism of injury, is/are the requested condition(s) a direct and proximate result of the industrial injury? Please explain why or why not.
  a. As aggravation
ADDITIONAL ALLOWANCE
  2. The injured worker has filed an application for the above mentioned additional allowance. Based on the current objective findings and documented objective findings, does the medical evidence support the existence of the requested additional condition(s) and is the condition a direct and proximate result of the industrial injury? Please explain.
  a. As aggravation.
MAXIMUM MEDICAL IMPROVEMENT
  3. Based on the current objective findings, documented objective findings, and allowed conditions. In your medical opinion, has the injured worker reached maximum medical improvement (MMI)? MMI means the condition has stabilized and no fundamental, functional or physiological change can be expected in the condition despite continued medical treatment and/or rehabilitation. Please present rationale.
  a.

If the injured worker has not reached MMI, based on a reasonable degree of medical certainty, when would you expect MMI to be reached?

  b. If the injured worker has not reached MMI, is vocational rehabilitation appropriate? Please specify services recommended.
TREATMENT ISSUES
  4. Based on the allowed conditions, has the treatment to date been medically necessary and appropriate? Please explain why or why not.
  5. Based on the allowed conditions, is further medical treatment needed? Please explain.
SECOND SURGICAL OPINION
  6. Based on the examination and documented objective records and allowed conditions, is the request for surgery medically substantiated as casually related to the above injury? Please explain.
RETURN TO WORK
  7.

Based on the current objective findings and allowed conditions, can the injured worker return to work with or without restrictions? If restrictions exist, please identify these restrictions.

TEMPORARY TOTAL DISABILITY
  8.

Based on the current objective findings, documented objective findings and allowed conditions, is the request for temporary total disability medically from, to substantiated as causally related to the allowed conditions?

PERMANENT PARTIAL DISABILITY (C-92)
  9. Based on the current objective findings and allowed conditions, is the injured worker capable of performing any form of remunerative employment? Please indicate the type of work capable of being performed. Please present rationale.
  10. In your medical opinion and based on a reasonable degree of medical certainty and the allowed conditions, it’s the injured worker permanently and totally disabled? Please present rationale.
C-92 EXAMINATION/REVIEW
  11.

Based on the current objective findings, allowed conditions/ICD codes, and the most recent edition of the AMA Guides to the Evaluations of Permanent Impairment, does it appear that the injured worker sustained a percentage of permanent partial impairment? If so, please present that percentage in terms of whole person.

  a.

The injured worker has applied for an increase to his/her previous permanent partial award of %. What, if any, change do you recommend to this prior award?

PSYCHOLOGICAL EXAMINATIONS
  12. Based on the current DSM IV criteria and documented psychological findings, is/are the requested psychological condition(s) supported? Please present the criteria.
  a. What is the normal onset of this type of diagnosis?
  b. What is the normal recovery period for this condition(s)?
  c. Is/are the alleged condition(s) a direct and proximate result of the industrial injury?
  d. If the condition was present prior to the injury, did the injury aggravate the psychological condition?
  e.

If, in your opinion, the psychological condition is present, what should current and future treatment include? Please indicate frequency and duration.

MEDICATION UTILIZATION REVIEW
  13. Based on the medical documentation reviewed and the conditions in the claim are the Therapeutic Classes of drugs currently being prescribed reasonably related, medically substantiated, and appropriate for the treatment of the allowances in the claim? Please explain your rationale, particularly addressing whether the treating physician has provided adequate medical justification for each Therapeutic Class of drugs being prescribed.
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