The FORM 107-I, also known as the Medical Report - Injury, represents a critical document within the Commonwealth of Kentucky's Department of Workers' Claims framework. Revised in April 2005, this form serves as a comprehensive tool for recording detailed medical information following a work-related injury. It captures the injured party's (plaintiff's) personal and employment details, the examination specifics by the physician, and a thorough account of any treatments previously or currently being administered. Moreover, the form includes sections for documenting the results of any physical examinations and diagnostic tests that were conducted, details of any surgeries performed, and the diagnosis and causation related to the work injury. The form requires the physician to evaluate whether the work-related injury was the cause of the plaintiff's complaints and to explain the causal relationship between the injury and the condition diagnosed. Additionally, it assesses the plaintiff's permanent impairment based on the most recent American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, including any pre-existing impairments. The form concludes with the physician's certification of the information provided. Given its role in adjudicating workers' compensation claims, the meticulous completion of each section of FORM 107-I is essential for assisting administrative law judges in making informed decisions about the occupational implications of work-related injuries.
| Question | Answer |
|---|---|
| Form Name | Form 107 I |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | draft 107 I form 107 kentucky |
FORM 107 - I
Medical Report - Injury
Revised April 2005
COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS
MEDICAL REPORT OF
DR._____________________________
FILED:
Do not write in this space
A. |
PLAINTIFF INFORMATION |
1.Plaintiff’s name: _________________________________________________________________________
2.Address: _______________________________________________________________________________
3.Social Security number: ___________________________________________________________________
4.Date of birth: ____________________________________________________________________________
5.Plaintiff's job title and employer: ____________________________________________________________
6.Date of examination(s): ___________________________________________________________________
7. |
Purpose of examination: |
ο Treatment |
οEvaluation requested by ________________________________________
οUniversity evaluation
8.Prior examination by this physician (if any) and date: ______________________________________
B. |
PLAINTIFF HISTORY |
Plaintiff related history of complaints or alleged injury as follows:
C. |
TREATMENT - Prior and Current |
Based upon a review of records and/or history related by plaintiff, treatment provided for this injury has been as follows: (Include periods of hospitalization.)
D. |
PHYSICAL EXAMINATION |
Results of physical examination, including objective medical findings to support complaints and/or diagnosis
E. |
DIAGNOSTIC TESTING |
Check the applicable block for any testing reviewed and relied upon for medical conclusions.
|
Test |
Date |
Personally Reviewed |
Summary of Results |
|
|
|
ο |
|
ο Yes |
ο No |
|
|
|
ο CT Scan |
|
ο Yes |
ο No |
|
|
|
ο MRI |
|
ο Yes |
ο No |
|
|
|
ο Myelogram |
|
ο Yes |
ο No |
|
|
|
ο EMG/NCV |
|
ο Yes |
ο No |
|
|
|
ο Other (specify) |
|
ο Yes |
ο No |
|
|
|
|
|
|
|
|
|
F. |
|
SURGICAL PROCEDURE(S) |
|
|
||
Specify type and date of any surgical procedure. Include operative note if surgery performed by this examining physician.
G.DIAGNOSIS
H.CAUSATION
Within reasonable medical probability, was plaintiff's injury the cause of his/her complaints? ο Yes ο No If the employee sustained more than one injury, which is the cause of his/her complaints?
I. |
EXPLANATION OF CAUSAL RELATIONSHIP |
Explain how the
J.IMPAIRMENT
1.Using the most recent AMA Guides tothe Evaluation of Permanent Impairment, theplaintiff's permanent wholeperson
impairment is |
|
%. |
2.Chapter and Tables utilized to arrive at impairment rating for injuries other than spinal injuries.
Body Part or System |
Chapter No. |
Table No. |
% Impairment of the Whole Person |
|
|
|
|
a. |
|
|
|
|
|
|
|
b. |
|
|
|
|
|
|
|
c. |
|
|
|
3.Plaintiff had an active impairment prior to this injury. οYes ο No
A.For affirmative answer, specify condition producing active impairm
________________________________________________________________________________
B.For affirmative answer, specify percentage of impairment due to the prior active condit
________________________________________________________________________________
4.Date on which maximum medical improvement was reached:_______________ 20___.
K.RESTRICTIONS
1.The plaintiff described the physical requirements of the type of work performed at the time of injury as follows:
2.Does the plaintiff retain the physical capacity to return to the type of work performed at the time of injury? οYes ο
3.Which restrictions, if any, should be placed upon plaintiff’s work activities as the result of the injury?
L. |
CERTIFICATION and QUALIFICATIONS of PHYSICIAN |
I hereby certify that the above information is correct and that all opinions were formulated within the realm of reason medical probability. A copy of my curriculum vitae is attached if I have not obtained anDepartment of Workers’ Claims Physi Index Number.
Date: _______________________ |
_________________________________ |
|
Full name of Physician |
|
________________________
Department of Workers’ Claims Physician Index Number
Instructions for
Completion of Form
The medical report forms of the Department of Workers’ Claims are designed to provide relevant medical information to administrative law judges to assist in determining the occupational implications of a
1.All information must be typed or neatly printed.
2.The Department of Workers’ Claims maintains a Physician Index with curricula vitae of physicians. Physicians may be included in the index by tendering a copy of a current curriculum vitae with a request for inclusion to:
Physicians Index Clerk, Department of Workers’ Claims, 657 Chamberlin Avenue, Frankfort, Kentucky 40601.
3.Use of the most recent edition of the AMA Guides to the Evaluation of Permanent Impairment is mandated by statute. Reference should be made to page numbers and tables only from the most recent edition for all physical injuries. For psychiatric conditions, the class of impairment should be stated, with reference to impairment ratings provided in prior editions.
4.For Form 108, height of a plaintiff should be measured in centimeters and without shoes. If the plaintiff’s height is an odd number of centimeters, the next highest even height in centimeters shall be used.
5.Objective medical findings to support a medical diagnosis means information gained through direct observation and testing of the plaintiffs, applying objective or standardized methods. KRS 342.0011(33).
6.Medical opinions must be founded on reasonable medical probability, not on mere possibility or speculation. Young v. Davidson, Ky., 463 S.W.2d 924 (1971).
7.
8.Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which
is a crime.
Revised 1/26/05