Get Initial Workers' Compensation Medical Report - State Of Illinois

This guide provides clear and supportive instructions for completing the Initial Workers' Compensation Medical Report for the State of Illinois online. With detailed steps, users will navigate through each section of the form effectively.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your online editor.
2. Enter the employee’s name in the designated field. Make sure to include the full name as it appears on official documents.
3. Fill in the date of the report. This is the date when you are completing the form.
4. Provide the agency or facility name where the employee is based.
5. Record the date of the accident here to reflect when the injury occurred.
6. Fill in the name of the family doctor of the employee. If there is no family doctor, this field may be left blank.
7. In section B, include the date examined as well as the names of any specialists, chiropractors, or others involved in the care.
8. Indicate the height and weight of the employee in the specified fields.
9. Describe the history of the accident in detail, focusing on what led to the injury.
10. Document any previous injuries or illnesses relevant to the current claim.
11. List the names of other physicians involved in the case, if applicable.
12. In section C, provide diagnostic codes and describe the nature and extent of the injuries sustained.
13. Outline the treatment provided, including any surgeries or dressings applied in section D.
14. Specify any medications given or prescribed to the employee.
15. Attach any relevant X-ray results or reports as necessary.
16. In section E, provide the prognosis and estimated dates for the employee's return to work with and without restrictions.
17. Complete the final report section if the treatment is no longer being provided, including the name of the doctor and their office address.
18. Sign the document where indicated as the doctor completing the report.
19. Finally, save your changes, download the form, print it, or share it as required by your processes.

Complete your documents online to ensure prompt processing of your workers' compensation claims.