Get Physicians Evaluation Of Permanent And Stationary State Of Ca Form

Completing the Physicians Evaluation Of Permanent And Stationary State Of Ca Form is an essential step for reporting a patient's permanent disability evaluation. This guide will walk you through each section of the form, providing clear instructions to help you fill it out efficiently and accurately.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form in your preferred editing tool.
2. Begin by entering the patient's information, including their last name, middle initial, first name, sex, date of birth, address, city, state, zip code, occupation, social security number, and phone number.
3. Next, provide the claims administrator or insurer’s contact details. This includes their name, address, phone number, city, state, and zip code.
4. Fill in the employer's information, detailing the employer's address, city, state, and zip code.
5. Address the injury details by including the date of injury, last date worked, date of examination, and the date the patient became permanent and stationary.
6. Describe how the injury or illness occurred in the designated field.
7. Record the patient's complaints and provide relevant medical history, objective findings from physical examinations, and diagnostic test results.
8. List the diagnoses along with their corresponding ICD-9 codes.
9. Evaluate the patient's ability to return to their usual occupation, indicating whether or not the job caused the injury or illness.
10. Discuss any pre-existing impairments impacting the patient's permanent disability.
11. Assess the subjective findings, detailing the frequency and severity of symptoms, and correlate them with any precipitating activities.
12. Document any restrictions or preclusions the patient experiences related to work.
13. Outline any expected future medical treatments needed for the patient's condition.
14. List any other healthcare professionals who contributed to the report and provide details on the information reviewed to prepare the report.
15. Finally, the primary treating physician must sign and declare the report's accuracy, including their licensing information, execution location, printed name, specialty, address, city, state, zip code, and phone number.
16. Once completed, save the changes, then choose to download, print, or share the form as necessary.

Complete your documents online today and ensure your forms are ready for submission.