Mississippi Workers' Compensation Commission
MEDICAL REPORT
THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE MISSISSIPPI WORKERS' COMPENSATION LAW AND MUST BE FILED WITH CARRIER IMMEDIATELY.
PRELIMINARY REPORT PROGRESS REPORT FINAL REPORT
CARRIER FILE #
DATE OF BIRTH
Q Q Q
Failure to submit this report will jeopardize payment of fees.
EMPLOYEE (NAME AND ADDRESS - INCLUDE CITY, STATE and ZIP) SOCIAL SECURITY NUMBER
PRINT OR TYPE
MWCC #
GENERAL INFORMATION (ALL REPORTS)
AGE
SEX
DATE OF INJURY
DATE DISABILITY BEGAN
EMPLOYER (NAME AND ADDRESS - INCLUDE CITY, STATE and ZIP)
INSURANCE CARRIER (NAME AND ADDRESS - INCLUDE CITY, STATE and ZIP)
FEIN:
FEIN:
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM (E) DIAGNOSIS CODE BY LINE)
1 2 3 4
(A) DATE(S) OF SERVICE FROM TO (B) Place of Service (C) Type of Service (D) PROCEDURES, SERVICES OR SUPPLIES (Explain unusual Circumstances) INCLUDE DRUGS PRESCRIBED (E) DIAG CODE (F) $ CHARGES (G) DAYS OR UNITS
PATIENT'S DESCRIPTION OF ACCIDENT OR OCCUPATIONAL ILLNESS
HOSPITAL NAME/ADDRESS IF HOSPITALIZED
PRELIM./PROGRESS
NOTE ANY CHANGE IN DIAGNOSIS MADE ON ANY PREVIOUS REPORT AND EXPLAIN.
SERVICES ENGAGED BY
IF PATIENT HAS A PRIOR IMPAIRMENT CONTRIBUTING TO PRESENT DISABILITY, GIVE PARTICULARS.
IS CONDITION WORK RELATED? IF SO, DESCRIBE
DATE FIRST TREATMENT
EXPECTED DATE MMI
DATE PATIENT REFUSED TREATMENT
DATE PATIENT STOP TREAT. W/O ORDER
DATE DISCHARGED AS CURED/MAX MED IMP.
DATE ABLE TO RETURN WORK
VOCATIONAL REHABILITATION WILL BE UNLIKELY PROBABLE NECESSARY
Q LIGHT Q NORMAL
IS PATIENT CAPABLE OF DOING SIMILAR/OTHER EMPLOYMENT AS BEFORE INJURED? IF NO, WHY?
FINAL REPORT
DOES PATIENT HAVE ANY PERMANENT DISABILITY RESULTING FROM THIS INJURY? IF SO, GIVE PART OF BODY AND PERCENT OF DISABILITY (INCLUDING VISION AND HEARING IF AFFECTED).
_______ %
PHYSICAL RESTRICTIONS, IF ANY
WAS THERE FACIAL OR HEAD DISFIGUREMENT? IF YES, DESCRIBE FULLY.
GEN./ALL
DOCTOR'S NAME AND ADDRESS
DOCTOR'S ID NUMBER
DATE
SIGNATURE
MWCC Form B9,27 (6-96)
AMPUTATION CHART ON BACK