This form is required to be used for ratings prepared pursuant to the 2005 Permanent Disability Rating Schedule and the AMA Guides to the Evaluation of Permanent Impairment (5th Ed.).
When: it should be completed if the patient has residual effects from the injury or may require future medical care.
Permanent and stationary: in such cases, it should be completed once the patient's condition becomes permanent and stationary.
QME or AME: this form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation.
| Question | Answer |
|---|---|
| Form Name | DWC Form PR-4 |
| Form Length | 6 pages |
| Fillable? | Yes |
| Fillable fields | 121 |
| Avg. time to fill out | 21 min |
| Edition | Rev 02/2016 |
| Issuing agency | State of California Division of Workers' Compensation |
| Reported to | The claims administrator |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | PR-4, PR4, DWC Form PR-4, DWC PR-4, Primary Treating Physician's Permanent and Stationary Report |
| Official source | DWC Form PR-4 (Rev 02/2016), State of California Division of Workers' Compensation |
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