Form 5021 PDF Details

The 5021 form, officially titled "Doctor's First Report of Occupational Injury or Illness," serves a critical function within California's workers' compensation system. This essential document must be completed by a physician following the initial examination of an employee who has suffered an occupational injury or illness. The form plays a significant role by ensuring that pertinent details about the injury or illness, including the nature and circumstances of the incident, subjective complaints, objective findings, diagnoses, and treatment plans, are communicated to the employer's workers' compensation insurance carrier or the insured employer. Compliance with the stipulation that this report be sent within five days of the initial examination can prevent the assessment of a civil penalty against the reporting physician. Moreover, in cases of diagnosed or suspected pesticide poisoning, the form mandates additional reporting to the Department of Industrial Relations and local health officers, underscoring the legal requirements aimed at safeguarding public health and facilitating the timely and effective administration of workers' compensation benefits. The form also addresses matters of consent and privacy, emphasizing the legal protections and obligations concerning the personal information of individuals involved in workers' compensation claims. By illustrating the procedure and legal standards that govern the reporting of occupational injuries or illnesses in California, the 5021 form manifests the structured approach towards ensuring workplace safety, health, and welfare, as well as the rights of workers to compensation and medical care following workplace incidents.

QuestionAnswer
Form NameForm 5021
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesform 5021, california form report injury, report occupational, california form doctor

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STATE OF CALIFORNIA

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DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS

 

 

 

Within 5 days of your initial examination, for every occupational injury or illness, send two copies of this report to the employer's workers' compensation insurance carrier or the insured employer. Failure to file a timely doctor's report may result in assessment of a civil penalty. In the case of diagnosed or suspected pesticide poisoning, send a copy of the report to Department of Industrial Relations, P.O. Box 420603, San Francisco, CA 94142-0603, and notify your local health officer by telephone within 24 hours.

1.Insurer Name and Address

2.Employer Name

3.

Address

No. and Street

 

City

 

Zip Code

4.

Nature of business (e.g. food manufacturing, building construction, retailer of women's clothes.)

 

 

5.

Patient Name

(first Name, middle initial

, last name)

6. Sex

7. Date of Birth

8.

Address

No. and Street

City

Zip Code

 

9.Phone Number

 

 

 

 

 

 

 

10.

Occupation (Specific job title)

11. Social Security Number

12. Address No.& Street Where Inj. Occurred

City Where Injury Occ.

County

13. Date and hour of injury or onset of illness

14.

Date last worked

15. Date and hour of 1st exam or treatment

16. Have you or your office previously rendered treatment

Patient please complete this portion, if able to do so. Otherwise, doctor please complete immediately, inability or failure of a patient to complete this portion shall not affect his/her rights to workers' compensation under the California Labor Code.

17.Describe how the accident or exposure happened. (Give specific object, machinery or chemical. Use reverse side if more space is required.)

18.SUBJECTIVE COMPLAINTS

19.Objective Findings

A.Physical Examination

B.X-ray and laboratory results (State if none or pending.)

Form 5021 (Rev. 5) 10/2015

Sheet 1 of 3

STATE OF CALIFORNIA DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS

20. DIAGNOSES(if occupational illness specify etiologic agent and duration of exposure.) Chemical or toxic compounds involved?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

21. Are your findings and diagnosis consistent with patient's account of injury or onset of illness?

22. Is there any other current condition that will impede or delay patient's recovery?

23.TREATMENT RENDERED (Use reverse side if more space is required.)

24.If further treatment required, specify treatment plan/estimated duration.

25.If hospitalized as inpatient, give hospital name and location

Date admitted

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

ICD-10

If "no," please explain below:

If "yes," please explain below:

Estimated length of stay

26.WORK STATUS - Is patient able to perform usual work? If "no", date when patient can return to

Yes

No

Regular work

Modified work

Specify restrictions

Form 5021 (Rev. 5) 10/2015

Sheet 2 of 3

STATE OF CALIFORNIA

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS

Physician Signature: (original signature, do not stamp)

I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code section 139.3.

Physician signature

 

 

Cal. License Number:

 

Executed at:

 

 

 

Date (mm/dd/yyyy):

 

Physician Name

 

 

 

Specialty:

 

 

Physician address:

 

 

 

Phone Number

 

 

Any person who makes or causes to be made any knowingly fraudulent material statement or material representation for the

purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.

PRIVACY NOTICE: The Administrative Director is authorized to maintain the records of the Division of Workers' Compensation (DWC). (Cal. Lab. Code

§126.) The Information Practices Act of 1977 and the Federal Privacy Act require the Administrative Director to provide this notice to individuals who submit information to the DWC pertaining to a workers' compensation claim. (Cal. Civ. Code § 1798.17; Public Law 93-579.)

The principal purpose for requesting information from injured workers, dependents, lien claimants, physician, employers or their representatives is to administer the California workers' compensation system. Each form shows which fields are required to be completed for DWC to process the form. If a required field in a form is incomplete or unreadable, the DWC may return the form to the individual for correction or may reject the form. Providing a social security number is required on this form pursuant to Labor Code § 6409. If you do not provide your security number, the DWC may return the form to you for correction or reject the form. If you do not have a social security number, indicate this in the space provided for the injured worker's social security number. As permitted by law, social security numbers are used to help properly identify injured workers and to conduct statistical research as allowed under the Labor Code.

As authorized by law, information furnished on this form may be given to: you, upon request; the public, pursuant to the Public Records Act; a governmental entity, when required by state or federal law; to any person, pursuant to a subpoena or court order pursuant to any other exception in Civil Code § 1798.24.

An individual has a right of access to records containing his/her personal information that are maintained by the Administrative Director. An individual may also amend, correct, or dispute information in such personal records. (Cal. Civ. Code §§ 1798.34-1798.3.) You may request a copy of the DWC's policies and procedures for inspection of records at the address below. Copies of the procedures and all records are ten cents ($0.10) per page, payable in advance. (Cal. Civ. Code § 1798.33.) Requests should be sent to: Division of Workers' Compensation- Medical Unit, P.O. Box 71010, Oakland, CA 94612. Tel: (510)

286-3700 or (800) 794.6900. Fax: (510) 622-3467.

Form 5021 (Rev. 5) 10/2015

Sheet 3 of 3

How to Edit Form 5021 Online for Free

We have used the efforts of the best software engineers to design the PDF editor you are going to work with. Our software allows you to prepare the california doctor report file easily and don’t waste time. Everything you should do is adhere to the following quick directions.

Step 1: Choose the button "Get Form Here" on the following webpage and select it.

Step 2: Now, you can begin modifying your california doctor report. The multifunctional toolbar is available to you - insert, delete, alter, highlight, and carry out other sorts of commands with the content in the form.

For every single section, complete the content asked by the application.

portion of blanks in doctors first report

You should submit the Address, No and Street, City, Zip Code, Phone Number, Occupation Specific job title, Social Security Number, Address No Street Where Inj, City Where Injury Occ County, Date and hour of injury or onset, Date last worked, Date and hour of st exam or, Have you or your office, Patient please complete this, and Describe how the accident or area with the necessary details.

Finishing doctors first report part 2

It is vital to provide some information within the box A Physical Examination, B Xray and laboratory results, Form Rev, and Sheet of.

Filling out doctors first report stage 3

You have to define the rights and responsibilities of every party in paragraph STATE OF CALIFORNIA DOCTORS FIRST, DIAGNOSESif occupational illness, ICD, ICD, ICD, ICD, ICD, ICD, ICD, ICD, ICD, ICD, ICD, ICD, and Are your findings and diagnosis.

Completing doctors first report part 4

Fill out the template by analyzing all these sections: Are your findings and diagnosis, If no please explain below, Is there any other current, If yes please explain below, TREATMENT RENDERED Use reverse, If further treatment required, If hospitalized as inpatient give, Date admitted, Estimated length of stay, WORK STATUS Is patient able to, Yes, If no date when patient can return, Regular work, and Modified work.

part 5 to finishing doctors first report

Step 3: Hit the "Done" button. You can now export the PDF document to your device. Aside from that, it is possible to deliver it by email.

Step 4: In order to avoid any hassles in the future, try to get around several duplicates of the form.

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