DFS-F5-DWC-25 (1).doc - Florida Workers Compensation...

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Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 1 BEFORE COMPLETING THIS FORM, PLEASE CAREFULLY REVIEW THE INSTRUCTIONS BEGINNING ON PAGE 3 NOTE: Health care providers shall legibly and accurately complete all sections of this form, limiting their responses to their area of expertise. 1 . Insurer Name: 2 . Visit/Review Date: / / 5. FOR INSURER USE ONLY 3. Injured Employee (Patient) Name: 4. Date of Birth: / / 6. Date of Accident: / / 7. Employer Name 8. Initial visit with this physician? a) NO b) YES SECTION I CLINICAL ASSESSMENT / DETERMINATIONS 9. No change in Items 9 – 13d since last reported visit. If checked, GO TO SECTION II. 10. Injury/ Illness for which treatment is sought is: a) NOT WORK RELATED b) WORK RELATED c) UNDETERMINED as of this date 11. Has the patient been determined to have Objective Relevant Medical Findings? Pain or abnormal anatomical findings, in the absence of objective relevant medical findings, shall not be an indicator of injury and/or illness and are not compensable. a) NO b) YES c) UNDETERMINED as of this date If YES or UNDETERMINED, explain: 12. Diagnosis(es): 13. Major Contributing Cause: When there is more than one contributing cause, the reported work-related injury must contribute more than 50% to the present condition and be based on the findings in Item 11. a) Is there a pre-existing condition contributing to the current medical disorder? a 1 ) NO a 2 ) YES a 3 ) UNDETERMINED as of this date b) Do the objective relevant medical findings identified in Item 11 represent an exacerbation (temporary worsening) or aggravation (progression) of a pre-existing condition? b 1 ) NO b 2 ) exacerbation b 3 ) aggravation b 4 ) UNDETERMINED as of this date c) Are there other relevant co-morbidities that will need to be considered in evaluating or managing this patient? c 1 ) NO c 2 ) YES d) Given your responses to the Items above, is the injury/illness in question the major contributing cause for: d 1 ) NO d 2 ) YES the reported medical condition?
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