Get Request For Impairment Rating Form 42 - Mywcinfo

Filling out the Request For Impairment Rating Form 42 is an important step in the workers' compensation process. This comprehensive guide will provide clear and concise instructions to help you complete the form accurately and effectively online.

Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the form and open it in the digital editor.
2. Begin by entering the injured worker information in the designated fields. This includes the patient's name and social security number.
3. Next, provide the employer or insurer information. Include the name of the employer, date of injury, address, and contact person with their telephone number.
4. In the body parts or organs being evaluated section, list the specific areas that require assessment. If applicable, indicate whether it is a limb and specify left or right.
5. For eye injuries, specify which eye was injured and note if there is a complete or permanent loss of sight or reduction in vision.
6. You will need to indicate the percentage of complete and permanent loss of function for each specified body part.
7. Provide the date when maximum medical improvement is likely to have occurred.
8. Indicate the evaluation date and what standards were utilized during your assessment, such as AMA guidelines.
9. In your medical opinion, respond to whether the patient has work capacity and whether they should be referred for a physical capacities evaluation.
10. Finally, complete the report date and signature section to finalize your submission.
11. Once all sections are complete, you can save your changes, download, print, or share the form as needed.

Start filling out your Request For Impairment Rating Form 42 online today to ensure a smooth claims process.