Get Workers' Compensation Medical Form - Nh.gov - Nh

Completing the Workers' Compensation Medical Form accurately is essential for ensuring timely reimbursement for medical services related to work-related injuries. This guide provides a clear and concise overview of how to fill out the form online, supporting both health professionals and workers.

Follow the steps to complete the Workers' Compensation Medical Form online:

1. Press the ‘Get Form’ button to acquire the Workers' Compensation Medical Form and open it in your chosen editor.
2. Begin by entering the employee's personal information, including their name, social security number, and occupation in the designated fields.
3. Fill in the employer's details, including the employer's name and work telephone number.
4. Indicate the date the employee last worked and provide the employer's address, along with the name of the Workers' Compensation insurer.
5. The health professional must complete the section on visit type, documenting whether it is an initial or follow-up visit and recording the injury date and time.
6. Provide a detailed statement of the incident as described by the worker, as well as their complaints and any relevant diagnosis or prognosis.
7. Outline the treatment plan clearly, indicating the professional's opinion on whether the injury and disability resulted from the described incident.
8. Evaluate employee work capability by marking appropriate boxes to indicate if they can continue working and under what conditions.
9. Document any restrictions on the employee's abilities, including activities like bending, kneeling, or lifting. Specify the maximum weights the employee can lift or carry.
10. State if the employee has reached maximum medical improvement and whether the injury has caused permanent impairment.
11. Ensure all medical notes are attached to the bill and the health professional certifies the accuracy of the provided information with their signature, printed name, federal ID number, date of visit, and contact information.
12. Finally, make sure to save changes, then download, print, or share the completed form as needed.

Complete the Workers' Compensation Medical Form online to ensure efficient processing of your claim.