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State of California Division of Workers' Compensation

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PRIMARY TREATING PHYSICIAN'S PROGRESS REPORT (PR-2)
Check the boxes which indicate why you are submitting a report at this time. If the patient is "Permanent and Stationary" (i.e., has reached maximum medical improvement), do not use this form. You may use DWC Forms PR-3 or PR-4.
Periodic Report (required 45 days after last report) Change in treatment plan Released from care Change in work status Change in patient's condition Other: Need for referral or consultation Need for surgery or hospitalization Response to request for information Request for authorization

Patient: Last _________________________________First ________________________M.I._______________Sex _______ Address__________________________________City________________________ State ______Zip____________ Date of Injury________________ Date of Birth_____________________ Occupation SS # _____-_____-________ Phone (___)______________________ Claims Administrator: Name_______________________________________________ Claim Number_______________________________ Address_____________________________________City_____________________ State______Zip_____________ Phone ( ) ________________________________ FAX ( ) _____________________________________ Employer name: Employer Phone ( ) The information below must be provided. You may use this form or you may substitute or append a narrative report. Subjective complaints:

Objective findings: (Include significant physical examination, laboratory, imaging, or other diagnostic findings.)

Diagnoses: 1. 2. 3.

ICD-9 ______________________ ICD-9 ______________________ ICD-9 ______________________

Treatment Plan: (Include treatment rendered to date. List methods, frequency and duration of planned treatment(s). Specify consultation/referral, surgery, and hospitalization. Identify each physician and non-physician provider. Specify type, frequency and duration of physical medicine services (e.g., physical therapy, manipulation, acupuncture). Use of CPT codes is encouraged. Have there been any changes in treatment plan? If so, why?

DWC Form PR-2 (Rev. 06-05)

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PRIMARY TREATING PHYSICIAN'S PROGRESS REPORT (PR-2)
Work Status: This patient has been instructed to: Remain off-work until___________. Return to modified work on________________________ with the following limitations or restrictions (List all specific restrictions re: standing, sitting, bending, use of hands, etc.): Return to full duty on ___________________with no limitations or restrictions.

Primary Treating Physician: (original signature, do not stamp)

Date of exam: _________________

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 § 139.3.

Signature: ____________________________________ Cal. Lic. # ______________________________ Executed at: ___________________________________ Date: __________________________________ Name:________________________________________ Specialty: ________________________________ Address:______________________________________ Phone:___________________________________

DWC Form PR-2 (Rev. 06-05)

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