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Get Form 107 Kentucky
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How to fill out the Form 107 Kentucky online
Filling out Form 107 Kentucky is an essential step in reporting medical information for a work-related injury. This guide provides a clear, step-by-step approach to assist users in completing the form accurately and efficiently online.
Follow the steps to successfully complete Form 107 Kentucky online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by providing plaintiff information in Section A. Fill in the plaintiff’s name, address, social security number, date of birth, job title, employer, date of examination(s), and the purpose of the examination (treatment, evaluation requested, or university evaluation).
- In Section B, detail the plaintiff's medical history related to the complaints or alleged injury. Be thorough and clear in your descriptions.
- Section C requires you to summarize prior and current treatments received by the plaintiff, including any hospitalizations related to the injury.
- In Section D, provide the results from the physical examination, ensuring to include objective medical findings that support the complaints and diagnosis.
- For Section E, indicate any diagnostic testing carried out. You will need to check whether tests such as X-rays, CT scans, MRIs, or EMGs were reviewed and relied upon, specifying the dates and if you personally reviewed them.
- If any surgical procedures have occurred, specify the type and date in Section F, including operative notes if applicable.
- Complete Section G by providing a clear diagnosis for the plaintiff's condition.
- In Section H, answer whether the plaintiff's injury likely caused their complaints and clarify if there are multiple injuries.
- Section I asks for an explanation of how the work-related injury caused changes in the plaintiff's condition.
- In Section J, assess the plaintiff's permanent impairment based on the AMA guides. Indicate any previous conditions and their impact on the plaintiff's overall impairment.
- Section K focuses on work restrictions. Describe the physical requirements of the plaintiff's role and any limitations they may have due to their injury.
- In the Certification section, the physician must certify the information provided is correct. The physician should provide their full name, date, and Department of Workers’ Claims Physician Index Number.
- Once all sections are completed, ensure that all information has been input accurately. Users can save changes, download, print, or share the completed form as needed.
Complete your documents online with confidence by following this guide.
In Kentucky, injured workers have up to two years from the date of the injury to file a workers' comp claim. It is essential to act promptly, as delays can lead to complications. Filing your claim using Form 107 Kentucky ensures that you remain compliant with state regulations. Consider utilizing US Legal Forms for easy access to necessary documentation.
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