39-71-1036. Medical status form.
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39-71-1036 . Medical status form.
(1)The department shall create a medical status form to be provided to a health care provider providing treatment for a compensable injury or occupational disease.
(2)The form must contain, at a minimum, the following information:
(a)the worker's first and last names and claim number;
(b)the affected body part that is directly related to the compensable injury or occupational disease;
(c)the timeframe during which the treating physician recommends that the worker be completely off work;
(d)the date or anticipated date of the worker's release to modified duty;
(e)the date or anticipated date of the worker's release to full duty;
(f)any temporary work restrictions applicable to the worker;
(g)any permanent work restrictions applicable to the worker; and
(h)the date of the worker's next appointment.
(3)An insurer may request additional information from the health care provider not contained in the department's form.
(4)The treating physician or a designee shall complete the form following every office visit with the worker.