Get Ca Dwc Pr-4 2005

The California Division of Workers' Compensation Primary Treating Physician’s Permanent and Stationary Report (CA DWC PR-4) is an important document used to report a worker's permanent disability evaluation. This guide will assist users in accurately completing this form online, ensuring all necessary information is provided.

Follow the steps to fill out the form efficiently.

1. Click ‘Get Form’ button to access the CA DWC PR-4 and open it for completion.
2. Begin by filling in the patient section at the top of the form. Include the patient's last name, first name, middle initial, date of birth, sex, address, city, state, zip code, phone number, and social security number.
3. Next, provide details about the claims administrator/insurer. Include their name, address, city, state, zip code, and phone number.
4. Fill in the employer’s information, including the name, address, city, state, and zip code, along with the employer's phone number.
5. In the treating physician section, enter your name, address, city, state, zip code, and phone number.
6. Record important dates relevant to the case, such as the date of injury, last date worked, when the patient became permanent and stationary, and the date of the current examination.
7. Describe how the injury occurred and record the patient's complaints clearly.
8. Provide a relevant medical history, followed by objective findings derived from physical examination and diagnostic tests.
9. List all diagnoses with corresponding ICD-9 codes. Ensure to report any impairments and detail the whole person impairment (WPI) rating based on established criteria.
10. Complete the pain assessment section if applicable. Specify any additional impairment ratings related to pain.
11. Address apportionment by indicating if the permanent disability is caused solely by the workplace injury or other factors. Include a narrative for the determination.
12. Detail any future medical treatments anticipated for the patient and their needs moving forward.
13. Complete the functional capacity assessment, indicating any restrictions or limitations as applied to work tasks.
14. Provide your signature, declaration of accuracy, license number, executed date, and specialty at the bottom of the form.
15. Finally, review the completed form for accuracy. You can then save the changes, download, print, or share the form as needed.

Complete your CA DWC PR-4 online now to ensure timely processing of the report.