Loading
Form preview picture

Get CA DWC PR-2 2005

Use of CPT codes is encouraged. Have there been any changes in treatment plan If so why DWC Form PR-2 Rev. 06-05 Work Status This patient has been instructed to Remain off-work until. PRINT CLEAR State of California Division of Workers Compensation Additional pages attached PRIMARY TREATING PHYSICIAN S PROGRESS REPORT PR-2 Check the boxes which indicate why you are submitting a report at this time. If the patient is Permanent and Stationary i.e. has reached maximum medical improvement do not use this form. You may use DWC Forms PR-3 or PR-4. PRINT CLEAR State of California Division of Workers Compensation Additional pages attached PRIMARY TREATING PHYSICIAN S PROGRESS REPORT PR-2 Check the boxes which indicate why you are submitting a report at this time. If the patient is Permanent and Stationary i*e* has reached maximum medical improvement do not use this form* You may use DWC Forms PR-3 or PR-4. Periodic Report required 45 days after last report Change in treatment plan Change in work status Need for referral or consultation Change in patient s condition Need for surgery or hospitalization Released from care Response to request for information Request for authorization Other Patient Last First M. I. Sex AddressCity State Zip Date of Injury Date of Birth Occupation SS -- Phone Claims Administrator Name Claim Number Phone FAX Employer name Employer Phone The information below must be provided* You may use this form or you may substitute or append a narrative report. Subjective complaints Objective findings Include significant physical examination laboratory imaging or other diagnostic findings. Diagnoses ICD-9 Treatment Plan Include treatment rendered to date. List methods frequency and duration of planned treatment s. Specify consultation/referral surgery and hospitalization* Identify each physician and non-physician provider. Specify type frequency and duration of physical medicine services e*g* physical therapy manipulation acupuncture. Return to modified work on with the following limitations or restrictions List all specific restrictions re standing sitting bending use of hands etc* Return to full duty on with no limitations or restrictions. Primary Treating Physician original signature do not stamp Date of exam I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code 139. If the patient is Permanent and Stationary i*e* has reached maximum medical improvement do not use this form* You may use DWC Forms PR-3 or PR-4. Periodic Report required 45 days after last report Change in treatment plan Change in work status Need for referral or consultation Change in patient s condition Need for surgery or hospitalization Released from care Response to request for information Request for authorization Other Patient Last First M. Periodic Report required 45 days after last report Change in treatment plan Change in work status Need for referral or consultation Change in patient s condition Need for surgery or hospitalization Released from care Response to request for information Request for authorization Other Patient Last First M. I. Sex AddressCity State Zip Date of Injury Date of Birth Occupation SS -- Phone Claims Administrator Name Claim Number Phone FAX Employer name Employer Phone The information below must be provided* You may use this form or you may substitute or append a narrative report. .

How It Works

PR-4 rating
4.27Satisfied
55 votes

Tips on how to fill out, edit and sign Submitting online

How to fill out and sign Specify online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Feel all the key benefits of submitting and completing forms on the internet. With our platform completing CA DWC PR-2 will take a couple of minutes. We make that achievable through giving you access to our feature-rich editor effective at transforming/correcting a document?s original text, adding special fields, and putting your signature on.

Execute CA DWC PR-2 within a couple of minutes following the recommendations listed below:

  1. Pick the template you need from our library of legal form samples.
  2. Choose the Get form button to open it and begin editing.
  3. Fill out all the required boxes (they will be marked in yellow).
  4. The Signature Wizard will enable you to put your electronic autograph after you?ve finished imputing info.
  5. Put the relevant date.
  6. Look through the whole template to make certain you?ve filled out all the data and no corrections are required.
  7. Click Done and download the filled out form to the device.

Send your new CA DWC PR-2 in an electronic form right after you finish completing it. Your information is securely protected, because we keep to the latest security criteria. Become one of numerous happy users who are already submitting legal documents right from their houses.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing cpt

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to CA DWC PR-2

  • lic
  • PR-3
  • PR-4
  • append
  • cpt
  • hospitalization
  • diagnoses
  • periodic
  • submitting
  • referral
  • Acupuncture
  • specify
  • stationary
  • narrative
  • SUBJECTIVE
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.