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

Enter the Insurer Name.

Enter the Visit/Review Date, the Injured Employee (Patient) Name, the Date of Birth and the Social Security #.

Enter the Date of Accident and the Employer Name. For Initial visit with this physician? mark a) NO or b) YES.

Mark Item 9 for No change in Items 9 - 13d since the last reported visit; if checked, go to Section II.

Injury/Illness for which treatment is sought: mark a) NOT WORK RELATED, b) WORK RELATED or c) UNDETERMINED as of this date.

Has the patient been determined to have Objective Relevant Medical Findings? Mark a) NO, b) YES or c) UNDETERMINED as of this date. If YES or UNDETERMINED, explain. Pain or abnormal anatomical findings, in the absence of objective relevant medical findings, shall not be an indicator of injury and/or illness and are not compensable.

Enter the Diagnosis(es).

Major Contributing Cause: When there is more than one contributing cause, the reported work-related injury must contribute more than 50% to the present condition and be based on the findings in Item 11.

Is there a pre-existing condition contributing to the current medical disorder? Mark a1) NO, a2) YES or a3) UNDETERMINED.

Do the objective relevant medical findings identified in Item 11 represent an exacerbation (temporary worsening) or aggravation (progression) of a pre-existing condition? Mark b1) NO, b2) exacerbation, b3) aggravation or b4) UNDETERMINED.

Are there other relevant co-morbidities that will need to be considered? Mark c1) NO or c2) YES.

Is the injury/illness the major contributing cause for the reported medical condition (d1) NO or d2) YES), the treatment recommended (management/treatment plan) (d3) NO or d4) YES) and the functional limitations and restrictions determined (d5) NO or d6) YES)?

Mark 14 for Level I, Key issue: specific, well-defined medical condition, with clear correlation between objective relevant physical findings and patients' subjective complaints.

Mark 15 for Level II, Key issue: regional or generalized deconditioning. Treatment: physical reconditioning and functional restoration.

Mark 16 for Level III, Key issue: poor correlation between patient's complaints and objective, relevant physical findings, indicating both somatic and non-somatic clinical factors. Treatment: interdisciplinary rehabilitation and management. Mark 17 for Level undetermined as of this date.

Mark 18 for No clinical services indicated at this time; if checked, go to Section IV.

Mark 19 for No change in Items 20a - 20g since last report submitted; if checked, go to Section IV.

The following proposed, subsequent clinical service(s) is/are deemed medically necessary. This is a provider's written request for insurer authorization of treatment or services.

For a) Consultation with or referral to a specialist, identify specialty and provide rationale, identify principal physician, and mark a1) CONSULT ONLY, a2) REFERRAL & CO-MANAGE or a3) TRANSFER CARE.

For c) Physical Medicine, check the appropriate box and indicate specificity of services, frequency and duration, then enter the Specific instruction(s): c1) Physical/Occupational therapy, Chiropractic, Osteopathic or comparable physical rehabilitation; c2) Physical Reconditioning (Level II Patient Classification); c3) Interdisciplinary Rehabilitation Program (Level III Patient Classification).

Specify b) Diagnostic Testing and d) Pharmaceutical(s). List e) DME or Medical Supplies and g) Attendant Care. For f) Surgical Intervention, specify procedure(s) and mark f1) In-Office, f2) Surgical Facility or f3) Injectable(s) (e.g. pain management).

At the top of page 2, enter the Patient Name, D/A and Visit/Review Date.

Assignment of limitations or restrictions must be based upon the injured employee's specific clinical dysfunction or status related to the work injury. The presence of objective relevant medical findings does not necessarily equate to an automatic limitation or restriction in function.

Mark 21 for No functional limitations identified or restrictions prescribed as of the following date, and enter that date.

Mark 22 when the injured worker's functional limitations and restrictions are of such severity that he/she cannot perform activities, even at a sedentary level (e.g. hospitalization, cognitive impairment, infection, contagion), as of the following date, and enter that date.

Mark 23 when the injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions identified. Identify ONLY those functional activities that have specific limitations and restrictions for this patient. Use additional sheet if needed.

Identify the joint and/or body part. For each activity, enter the Load, the Frequency & Duration and the ROM/Position & Other Parameters.

Any functional limitations or restrictions assigned 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.

Patient has achieved maximum medical improvement? Mark a) YES and enter the Date, or mark b) NO. The form also has c) Anticipated MMI date, with a date to enter, and d) Anticipated MMI date cannot be determined at this time, each its own box.

Mark Yes or No for Future Medical Care Anticipated, and enter any Comments.

In Box 25, enter the % Permanent Impairment Rating (body as a whole) and the Body part/system.

Guide used for calculation of Permanent Impairment Rating (based on date of accident): mark a) 1996 FL Uniform PIR Schedule or b) Other, specify.

Is a residual clinical dysfunction or residual functional loss anticipated for the work-related injury? Mark a) YES, b) NO or c) Undetermined at this time.

Enter the Next Scheduled Appointment Date & Time.

Sign, and enter the Physician Group, the Date, the Physician DOH License #, the Physician Name (print name) and the Physician Specialty.

The Physician attests 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. The responses are consistent with the medical documentation regarding this patient, and have been shared with the patient.

The Physician certifies to any MMI / PIR information provided in this form.

If any direct billable services for this visit were rendered by a provider other than a physician, the provider completes the Provider Signature, Provider Name (print name), Date and Provider DOH License #.

The Physician signs the Attestation Statement.