| Report |
Due/Needed by Insurer |
What Information
Should Be Included In
the Report? |
Special Notes |
| Report of Industrial
Injury or Occupational
Disease (form) |
Immediately - within five
days of first visit. |
See form |
Only MD, DO, DC, ND,
DPM, DDS, ARNP, PA,
and OD may sign and be
paid for completion of
this form. |
| Self-Insurance:
Provider's Initial Report
(form) |
|
If additional space is
needed, please attach the
information to the
application. The claim
number should be at the
top of the page. |
|
| Sixty Day (narrative) |
Every sixty days when
only conservative
(nonsurgical) care has
been provided. |
(1) The conditions
diagnosed, including
ICD-9-CM codes and the
subjective complaints and
objective findings. |
Providers may submit
legible comprehensive
chart notes in lieu of sixty
day reports PROVIDED the
chart notes include all the
information required as
noted in the "What
Information Should Be
Included?" column. |
| Purpose: Support and
document the need for
continued care when
conservative
(nonsurgical) treatment is
to continue beyond sixty
days |
| |
|
(2) The relationship of
diagnoses, if any, to the
industrial injury or
exposure. |
However, office notes are
not acceptable in lieu of
requested narrative
reports and providers
may not bill for the report
if chart notes are
submitted in place of the
report. |
| |
|
(3) Outline of proposed
treatment program, its
length, components and
expected prognosis
including an estimate of
when treatment should be
concluded and
condition(s) stable. An
estimated return to work
date and the probability, if
any, of permanent partial
disability resulting from
the industrial condition. |
|
| Please see WAC 296-20-03021 and 296-20-03022 for
documentation
requirements for those
workers receiving opioids
to treat chronic
noncancer pain. |
|
|
(4) Current medications,
including dosage and
amount prescribed. With
repeated prescriptions,
include the plan and need
for continuing
medication. |
Providers must include
their name, address and
date on all chart notes
submitted. |
|
|
(5) If the worker has not
returned to work, indicate
whether a vocational
assessment will be
necessary to evaluate the
worker's ability to return
to work and why. |
|
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|
(6) If the worker has not
returned to work, a
doctor's estimate of
physical capacities
should be included. |
|
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|
(7) Response to any
specific questions asked
by the insurer or
vocational counselor. |
|
| Special
Reports/Follow-up
Reports (narrative) |
As soon as possible
following request by the
department/insurer. |
Response to any specific
questions asked by the
insurer or vocational
counselor. |
"Special reports" are
payable only when
requested by the insurer. |
| Consultation
Examination Reports
(narrative) |
At one hundred twenty
days if only conservative
(nonsurgical) care has
been provided. |
(1) Detailed history. |
If the injured/ill worker
had been seen by the
consulting doctor within
the past three years for
the same condition, the
consultation will be
considered a follow-up
office visit, not
consultation. |
| Purpose: Obtain an
objective evaluation of
the need for ongoing
conservative medical
management of the
worker. |
|
(2) Comparative history
between the history
provided by the attending
or treating provider and
injured worker. |
|
|
|
(3) Detailed physical
examination. |
|
| The attending or treating
provider may choose the
consultant. |
|
(4) Condition(s)
diagnosed including
ICD-9-CM codes,
subjective complaints and
objective findings. |
A copy of the
consultation report must
be submitted to both the
attending or treating
provider and the
department/insurer. |
|
|
(5) Outline of proposed
treatment program: Its
length, components,
expected prognosis
including when treatment
should be concluded and
condition(s) stable. |
|
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(6) Expected degree of
recovery from the
industrial condition. |
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(7) Probability of
returning to regular
work or modified work
and an estimated return
to work date. |
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(8) Probability, if any, of
permanent partial
disability resulting from
the industrial condition. |
|
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|
(9) A doctor's estimate of
physical capacities
should be included if the
worker has not returned
to work. |
|
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|
(10) Reports of
necessary, reasonable X
ray and laboratory
studies to establish or
confirm diagnosis when
indicated. |
|
| Attending Provider
Review of IME Report
(form) |
As soon as possible
following request by the
department/insurer. |
Agreement or
disagreement with IME
findings. If you disagree,
provide
objective/subjective
findings to support your
opinion. |
Payable only to the
attending provider upon
request of the
department/insurer. PAs
can concur with treatment
recommendations but not
PPD ratings. |
| Purpose: Obtain the
attending provider's
opinion about the
accuracy of the
diagnoses and
information provided
based on the IME. |
|
|
|
| Loss of Earning Power
(form) |
As soon as possible after
receipt of the form. |
See form |
Payable only to the
attending or treating
provider. |
| Purpose: Certify the loss
of earning power is due to
the industrial
injury/occupational
disease. |
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| Application to Reopen
Claim Due to Worsening
of Condition (form) |
Immediately following
identification of
worsening after a claim
has been closed for sixty
days. |
See form |
Only MD, DO, DC, ND,
DPM, DDS, ARNP, PA,
and OD may sign and be
paid for completion of
this form. |
| Purpose: Document
worsening of the
accepted condition and
need to reopen claim for
additional treatment. |
Crime Victims:
Following identification
of worsening after a claim
has been closed for
ninety days. |
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