Dfs F5 Dwc 25 Form – Fill Out and Use This PDF

Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 2

Assignment of limitations or restrictions must be based upon the injured employee's specific clinical

dysfunction or status related to the work injury. However, the presence of objective relevant medical findings

does not necessarily equate to an automatic limitation or restriction in function.

 21 No functional limitations identified or restrictions prescribed as of the following date: _________________.

22. The injured workers' functional limitations and restrictions, identified in detail below, are of such severity that he/she

cannot perform activities, even at a sedentary level (e.g. hospitalization, cognitive impairment, infection, contagion),

23. The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this patient. Identify joint and/or body part __________________________________. Use additional sheet if needed.

Walk

_

Other

COMMENTS:

Other choices; Skin Contact/ Exposure; Sensory; Hand Dexterity; Cognitive; Crawl; Vision; Drive/Operate Heavy Equipment; Environmental Conditions: heat, cold, working at heights, vibration; Auditory; Specific Job Task(s); etc.

NOTE: Any functional limitations or restrictions assigned above apply to both on and off the job activities, and are in effect until the next scheduled appointment unless otherwise noted or modified prior to the appointment date.

Specify those functional limitations and restrictions, in Item 23, which are permanent if MMI / PIR have been assigned in Item 24.

26.Guide used for calculation of Permanent Impairment Rating (based on date of accident - see instructions):

27.Is a residual clinical dysfunction or residual functional loss anticipated for the work-related injury?

b) NO c) Undetermined at this time. a) YES

“As the Physician, I hereby attest that all responses herein have been made, in accordance with the instructions as part of this form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation

If any direct billable services for this visit were rendered by a provider other than a physician, please complete sections below:

“I hereby attest that all responses herein relating to services I rendered have been made, in accordance with the instructions as part of this form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation regarding this patient, and have been shared with the patient."

FORM DFS-F5-DWC-25

COMPLETION/SUBMISSION INSTRUCTIONS

GENERAL INFORMATION

The Form DFS-F5-DWC-25 has been adopted by the Florida Division of Workers’ Compensation in Rule 69L-7.602, F.A.C., as the required reporting form for physicians to recommend medical treatment/ services and report the medical status of the injured employee to insurers/employers including the establishment of the date of maximum medical improvement and assignment of permanent impairment rating, when applicable, pursuant to Sections 440.13(4)(a) and 440.15(3)(d), F.S. The Form DFS-F5- DWC-25 shall be submitted by the provider to the insurer, and to the employer upon request, upon the occurrence of any actionable event (change in treatment plan, regime, therapies, prescriptions, or functional limitations or restrictions), and following the injured employee achieving maximum medical improvement, in accordance with the conditions and timeframes established in this rule. In instances where the form is submitted without the occurrence of any actionable event, receipt of new information or patient re-examination, it is anticipated that the provider will submit the form reflecting an unchanged patient status. No Form DFS-F5-DWC-25 shall be required in the instances defined in the Completion Exemptions section of these instructions.

Insurers/employers and providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of the injured employee’s medical treatment/status. Any other reporting forms may not be used in lieu of or supplemental to the Form DFS-F5-DWC-25.

Accurate completion of the Form DFS-F5-DWC-25 and the terms used herein do not create any access to medical services or alter any conditions associated with the provision or reimbursement of medical services other than as allowed in Section 440.13, F.S.

No reimbursement shall be made for completion of the Form DFS-F5-DWC-25. The Form DFS-F5- DWC-25 is the exclusive form to be used when reporting establishment of the date of maximum medical improvement and assignment of an impairment rating. It is the physician’s primary responsibility in treating the injured employee to apply provisions of Sections 440.09 and 440.13, F.S. when:

a. Evaluating an injury or illness,

b.Ordering, prescribing or rendering remedial treatment care or attendance, and

c.Assigning functional limitations or restrictions.

COMPLETION GUIDELINES

Physicians completing the Form DFS-F5-DWC-25 must apply the following guidelines:

•Accurate completion and submission of the Form DFS-F5-DWC-25 does not fulfill the provider requirement to obtain prior insurer approval and authorization for referrals, consultations, treatment plans, and/or other medically necessary services.

•Accurate completion and submission of the Form DFS-F5-DWC-25 is in addition to medical billing forms required pursuant to this rule.

•The Form DFS-F5-DWC-25 does not replace physician notes, medical records or required medical billing reports.

•Physician notes, medical records, or other relevant diagnostic tests and evaluations must be consistent with all information submitted on the Form DFS-F5-DWC-25, and shall document additional details of the medical services rendered to the injured employee.

•A copy of the Form DFS-F5-DWC-25 shall become part of the permanent medical records of the injured employee retained by the physician.

•Physicians shall provide a copy of the accurately completed Form DFS-F5-DWC-25 to the employer, upon request.

COMPLETION REQUIREMENTS

Providers required to complete the Form DFS-F5-DWC-25 are as follows:

•All physicians, including physician assistants and advanced registered nurse practitioners (ARNPs) under the supervision of a physician, who provide direct billable services immediately following the reported work related injury, regardless of location.

•Physicians providing preliminary treatment, care or attendance in the emergency room of a hospital licensed under Chapter 395, F.S. shall be required to accurately complete Items 1-8, 10, 11, 12, Section IV, and sign the Attestation Statement in Section VII.

•All principal physicians or physicians accepting consults, referrals or transfers of care (including physician assistants and ARNPs under the supervision of a physician) who provide initial or ongoing treatment, care or independent medical examinations.

COMPLETION EXEMPTIONS

Providers exempt from completing the DFS-F5-DWC-25 are as follows:

•Physicians providing only medical interpretation of diagnostic testing (i.e. radiographic films; lab specimens; electro-myographic findings; electro-encephalogram or electro-cardiogram tracings, etc.) without direct physician-to-patient encounter.

•Physicians performing diagnostic testing (i.e. electro-myography, eletro-nystagmography, injections, etc.) without performing a complete patient examination or evaluation. Examples of such services may be associated with nerve conduction studies, radiological studies, muscle biopsies to obtain specimens, etc.

•Anesthesiologists or ARNPs, under the supervision of a physician, who provide anesthesia services in the presence of an operating surgeon.

•Physicians functioning as a second surgeon or as an assistant surgeon and not as the primary surgeon.

COMPLETION/ SUBMISSION EXCEPTIONS

Physicians providing treatment when the patient is admitted to hospital for greater than 24 hours shall:

complete the Form DFS-F5-DWC-25 at the pre-admission office visit for scheduled hospital admissions, or

on the date of admission for unscheduled hospitalizations, and upon the date of discharge.

When Form DFS-F5-DWC-25 completion is related to the injured employee’s hospital admission (as listed above), the form shall be submitted to the insurer, and the employer upon request, by close of business on the next business day following completion.

•Physicians providing treatment when the patient is participating in an interdisciplinary pain

management program, interdisciplinary rehabilitation program or receiving more than three times