DWC-25 (Florida)

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

MonthDayYear
Date
4.Date of Birth

MonthDayYear
Date
5.Social Security #
8.Initial visit with this physician? a NOb YES7. Employer Name
6. Date of Accident

MonthDayYear
Date
SECTION I
7. Employer Name
9. No change in Items 9 - 13d since last reported visit. If checked, GO TO SECTION II.
CLINICAL ASSESSMENT / DETERMINATIONS
10.Injury/ Illness for which treatment is sought is:
NOT WORK RELATEDWORK RELATEDUNDETERMINED as of this datea NOb YESc UNDETERMINED as of this date
If YES or UNDETERMINED, explain
Diagnosis(es): 12.
a YES 2a UNDETERMINED as of this date 3a NO 1 Do the objective relevant medical findings identified in Item 11 represent an exacerbation temporary worsening bb aggravation 3b UNDETERMINED as of this date 4or aggravation progression of a pre-existing condition? b NO b exacerbation 1 2 Are there other relevant co-morbidities that will need to be considered in evaluating or managing this patient? cc YES 2c NO 1 Given your responses to the Items above, is the injury/illness in question the major contributing cause for: d d NOd YES the reported medical condition? 12 d NOd YES the treatment recommended management/treatment plan? 34 d NOd YES the functional limitations and restrictions determined? 56
a Is there a pre-existing condition contributing to the current medical disorder?Major Contributing Cause: When there is more than one contributing cause, the reported work-related injury must 13. contribute more than 50% to the present condition and be based on the findings in Item 11.Diagnosis(es): 12.If YES or UNDETERMINED, explain: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.SECTION II PATIENT CLASSIFICATION LEVEL10.Injury/ Illness for which treatment is sought is:
14. LEVEL I - Key issue: specific, well-defined medical condition, with clear correlation between objective relevant physical findings and patients' subjective complaints. Treatment correlates to the specific findings.Key issue: regional or generalized deconditioning i.e. deficits in strength, flexibility, endurance, and 15. LEVEL II - motor control. Treatment: physical reconditioning and functional restoration.
16. LEVEL III -Key issue: poor correlation between patient's complaints and objective, relevant physical findings, indicating17. LEVEL UNDETERMINED AS OF THIS DATE. SECTION III
6. Date of Accident
Attendant Care: g
MANAGEMENT / TREATMENT PLAN
No change in Items 20a - 20g since last report submitted. 19.
18. No clinical services indicated at this time.
If checked, GO TO SECTION IV
Consultation with or referral to a specialist. Identify principal physician: a
Consultation with or referral to a specialist. Identify principal physician: a
Identify specialty & provide rationale
a CONSULT ONLY 1 Diagnostic Testing: Specify b
a CONSULT ONLY 1 Diagnostic Testing: Specify ba REFERRAL & CO-MANAGE 2a TRANSFER CARE 3
Physical Medicine. Check appropriate box and indicate specificity of services, frequency and duration below: c
Identify specialty & provide rationalec Physical/Occupational therapy, Chiropractic, Osteopathic or comparable physical rehabilitation. 1 c Physical Reconditioning Level II Patient Classification 2 c Interdisciplinary Rehabilitation Program Level III Patient Classification 3 Specific instructions*** THIS IS A PROVIDER'S WRITTEN REQUEST FOR INSURER AUTHORIZATION OF TREATMENT OR SERVICES.The following proposed, subsequent clinical service(s) is/are deemed medically necessary. 20.
Pharmaceuticals specify: d
Pharmaceuticals specify: d
DME or Medical Supplies: e
Surgical Intervention - specify procedures: f
Pharmaceuticals specify: dDME or Medical Supplies: eSurgical Intervention - specify procedures: f
f In-Office: 1 f Surgical Facility: 2 f Injectables e.g. pain management: 3
f In-Office: 1 f Surgical Facility: 2 f Injectables e.g. pain management: 3
f In-Office: 1 f Surgical Facility: 2 f Injectables e.g. pain management: 3
f In-Office: 1 f Surgical Facility: 2 f Injectables e.g. pain management: 3
Form DFS-F5-DWC-25 (revised 1/31/2008) Page 1 of 2
Patient Name: D/A
Patient Name: D/A

MonthDayYear
Date
Visit/Review Date

MonthDayYear
Date
23. The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this patient. Identify joint and/or body part Use additional sheet if needed.
21 No functional limitations identified or restrictions prescribed as of the following date

MonthDayYear
Date
21 No functional limitations identified or restrictions prescribed as of the following date:
22. The injured workers' functional limitations and restrictions, identified in detail below, are of such severity that he/she cannot perform activities, even at a sedentary level (e.g. hospitalization, cognitive impairment, infection, contagion), as of the following date: Use additional sheet if needed.
23. The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this patient. Identify joint and/or body part Use additional sheet if needed.

MonthDayYear
Date
23. The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this patient. Identify joint and/or body part Use additional sheet if needed.

23. The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this patient. Identify joint and/or body part Use additional sheet if needed.

Rows	-	-	-

Functional Activity

Rows	Load	Frequency & Duration	ROM/ Position & Other Parameters
Bend y Carr Climb

Grasp Kneel Lift-floor > waist Lift-waist>overhead



Pull Push

Reach-overhead Sit Squat Stand



Twist Walk


Other
COMMENTS:

Functional ActivityAssignment of limitations or restrictions must be based upon the injured employee's specific clinical dysfunction or status related to the work injury. However, the presence of objective relevant medical findings does not necessarily equate to an automatic limitation or restriction in function.SECTION IV FUNCTIONAL LIMITATIONS AND RESTRICTIONSPatient Name: D/A:Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 2Visit/Review Date:Grasp Kneel Lift-floor > waist Lift-waist>overheadPull PushPull PushReach-overhead Sit Squat StandReach-overhead Sit Squat StandReach-overhead Sit Squat StandReach-overhead Sit Squat StandTwist WalkTwist WalkOther
Twist Walk
Other
COMMENTS
posure; Sensory; Hand Dexterity; Cognitive; Crawl; Vision; Drive/Operate Heavy Equipment; Other choices; Skin Contact/ Ex Environmental Conditions: heat, cold, working at heights, vibration; Auditory; Specific Job Task(s); etc.

NOTE: Any functional limitations or restrictions assigned above apply to both on and off the job activities, and are in effect until the next scheduled appointment unless otherwise noted or modified prior to the appointment date. Specify those functional limitations and restrictions, in Item 23, which are permanent if MMI / PIR have been assigned in Item 24.
SECTION V MAXIMUM MEDICAL IMPROVEMENT / PERMANENT IMPAIRMENT RATING
a YES, Date

MonthDayYear
Date
a YES, Date

MonthDayYear
Date
d Anticipated MMI date cannot be determined at this time.e Future Medical Care Anticipated: Comments
Yesf⁯No
24. Patient has achieved maximum medical improvement?
c Anticipated MMI date

MonthDayYear
Date
c Anticipated MMI date

MonthDayYear
Date
b NOc Anticipated MMI date:
d Anticipated MMI date cannot be determined at this time.e Future Medical Care Anticipated: Comments

MonthDayYear
Date
d Anticipated MMI date cannot be determined at this time.e Future Medical Care Anticipated: Comments

MonthDayYear
Date
_% Permanent Impairment Rating (body as a whole)
Body part/system
Body part/system
a 1996 FL Uniform PIR Schedulea YESb NOc Undetermined at this time.b Other, specify
Guide used for calculation of Permanent Impairment Rating (based on date of accident - see instructions):

Is a residual clinical dysfunction or residual functional loss anticipated for the work-related injury?
SECTION VI FOLLOW-UP
Next Scheduled Appointment Date & Time

MonthDayYear
Date
SECTION VII ATTESTATION STATEMENT
regarding this patient, and have been shared with the patient.

“As the Physician, I hereby attest that all responses herein have been made, in accordance with the instructions as part of this form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation "I certify to any MMI / PIR information provided in this form.”
Physician Group
Date

MonthDayYear
Date
Physician Signature

Clear
Physician DOH License #
Physician Name
Physician Specialty
If any direct billable services for this visit were rendered by a provider other than a physician, please complete sections below:
“I hereby attest that all responses herein relating to services I rendered have been made, in accordance with the instructions as part of this form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation regarding this patient, and have been shared with the patient.
Provider Signature

Clear
Provider DOH License #:
Provider Name
Date

MonthDayYear
Date
Form DFS-F5-DWC-25 (revised 1/31/2008) Page 2 of 2
Should be Empty:

Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 1

BEFORE COMPLETING THIS FORM, PLEASE CAREFULLY REVIEW THE INSTRUCTIONS BEGINNING ON PAGE 3

FOR INSURER USE ONLY

CLINICAL ASSESSMENT / DETERMINATIONS

MANAGEMENT / TREATMENT PLAN

SECTION V MAXIMUM MEDICAL IMPROVEMENT / PERMANENT IMPAIRMENT RATING

SECTION VI FOLLOW-UP

SECTION VII ATTESTATION STATEMENT

Provider DOH License #: