Dwc Form 73 – Fill Out and Use This PDF

I. GENERAL INFORMATION

Date Sent (for transmission purposes only):

1.

Injured Employee's Name

5a. Doctor’s/Delegating Doctor’s Name and Degree

5b. PA / APRN Name (if completing form)

2.

Date of Injury

3. Social Security Number (last

6.

Facility Name

9. Employer's Name

four) XXX-XX-

4.

Employee’s Description of Injury/Accident

7.

Facility/Doctor Phone and Fax Numbers

10.

Employer’s Fax Number or Email Address (if

known)

8.

Facility/Doctor Address (Street, City, State, ZIP Code)

11.

Insurance Carrier

12.

Carrier’s Fax Number or Email Address (if

known)

14. Posture Restrictions (if any):

17. Motion Restrictions (if any):

19. Misc. Restrictions (if any):

Max hours perday

0

2 4 6

8

Other:

Max hours perday

0 2 4 6 8

Other:

Max hours per day of work:

Standing

Walking

Sit/stretch breaks of ______ per ________

Sitting

Climbing stairs/ladders

Must wear splint/cast at work

Kneeling/squatting

Grasping/squeezing

Must use crutches at all times

Bending/stooping

Wrist flexion/extension

No driving/operating heavy equipment

Pushing/pulling

Reaching

Can only drive automatic transmission

Twisting

Overhead reaching

No skin contact with:

Other:

Keyboarding

No running

15. Restrictions Specific To (if applicable):

Other:

Dressing changes necessary at work

Left hand/wrist

Left leg

Right hand/wrist

Right leg

18. Lift/Carry Restrictions (if any):

No work /________

hours/day work:

Left arm

Back

May not lift/carry objects more than _____ lbs. for more

Right arm

Left foot/ankle

than _____ hours per day.

in extreme hot/cold environments

at heights or on scaffolding

Neck

Right foot/ankle

May not perform any lifting/carrying.

Other:

Must keep_____________________________

Other:

elevated

clean & dry

16. Other Restrictions (if any)

20. Medication Restrictions (if any):

Must take prescription medication(s)

Advised to take over-the-counter meds

Medication may make drowsy (possible

safety/driving issues)

IV: TREATMENT/FOLLOW-UP APPOINTMENT INFORMATION

21. Work Injury Diagnosis

22. Expected Follow-up Services Include:

Information:

Evaluation by the treating doctor on _____/ _____/ __________ at _____:_____ a.m./p.m.

Referral to/consult with ______________________________ on _____/ _____/ _________ at _____:_____ a.m./p.m.

Physical medicine _____ X per week for _____ weeks starting on _____/ _____/ _________ at _____:_____ a.m./p.m.

Special studies (list): ______________________________ on _____/ _____/ __________ at _____:_____ a.m./p.m.

None. This is the last scheduled visit for this problem. At this time, no further medical care is anticipated.

Date /Time of Visit:

Employee’s Signature

Visit Type:

Role of Health Care Practitioner:

Initial

Treating doctor

Consulting doctor

Designated doctor

Referral doctor

PA

Other doctor

Discharge Time:

HealthCarePractitioner’sSignature/License#

Follow-up

RME doctor

APRN

DWC073 Rev. 09/19

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Type of Doctor

When to File DWC Form-073

Where to File

Delivery Method

Deadline

Treating Doctor

• after the initial examination of the injured employee,

• injured employee

hand deliver;

at the time of the

regardless of the employee’s work status

electronic transmission,

examination

Referral Doctor

• when there is a change in the injured employee’s

with agreement (fax,

work status

email, or similar method)

Delegated Physician

• when there is a substantial change in the injured

Assistant (PA)

employee’s activity restrictions

or

• on a schedule requested by the insurance carrier

• insurance carrier

electronic transmission

within 2 working

as long as it is based on the injured employee’s

days of the

Delegated

scheduled appointments with the doctor (not to

examination

exceed one report every two weeks)

• employer

electronic transmission

Advanced Practice

Registered Nurse

unless recipient has not

(APRN)

provided a fax number or

email address; then by

personal delivery or mail

• after receiving a set of functional job descriptions

• injured employee

hand deliver unless no

within 7 days of

from the employer or insurance carrier listing

appointment is scheduled

receiving job

modified duty positions, including the physical and

before deadline; then

description or

time requirements of the positions, that the

electronic transmission

RME opinion

employer has available for the injured employee to

unless recipient has not

work

provided a fax number or

• after receiving a DWC Form-073 from a required

email address; then by

medical exam (RME) doctor that indicates the

mail

injured employee can return to work with or without

• insurance carrier

electronic transmission

restrictions

• employer

Designated Doctor

• after examination of an injured employee to

• injured employee

electronic transmission

within 7 working

address any question relating to return to work

• injured employee’s

unless recipient has not

days of the

representative (if any)

provided a fax number or

examination

NOTE: The designated doctor must file a narrative

email address; then by

report along with DWC Form-073.

other verifiable means

• insurance carrier

electronic transmission

• treating doctor

• division

fax to 512-490-1047

RME Doctor

• after examination of an injured employee

• injured employee

electronic transmission

within 7 days of

(subsequent to a Designated Doctor's

• injured employee’s

unless recipient has not

the examination

examination), if the RME doctor determines that the

representative (if any)

provided a fax number or

injured employee can return to work immediately

email address; then by

with or without restrictions

other verifiable means

• insurance carrier

electronic transmission

• treating doctor

DWC073 Rev. 09/19

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