Free 45547.pdf - Indiana

ATTENDING PHYSICIAN'S STATEMENT
State Form 45547 (R4 / 3-09)

STATE OF INDIANA State Personnel Department Benefits Division Disability Program This form Is confidential per IC 5-14-3-4(A) (9)

Mail completed form to: JWF Specialty Co., Inc. (Third Party Administrator) PO Box 40968 Indianapolis, IN 46240-0968 Telephone: (888) 818-7795 or (317) 574-7876 Fax: 317-574-7865

This form is to be completed without expense to the State of Indiana. THIS SECTION IS TO BE COMPLETED BY EMPLOYEE / PATIENT (Please print) Name of patient Name of agency Job title THIS SECTION TO BE COMPLETED BY PHYSICIAN I. HISTORY a.) When did symptoms first appear or accident happen? b.) Has the patient ever had the same or similar condition? (If Yes, state when and describe.) Yes No Unknown c.) Name(s) and address(es) of other treating physician(s). MALE FEMALE Date of birth (month, day, year)

Is the condition due to injury or sickness arising from patient's employment? Yes No Unknown II. DIAGNOSIS a.) Diagnosis (including any complications): ---------------------------------------------------------------------------------------------------------------

b.) CPT Code c.) If pregnancy, estimated date of delivery: d.) Subjective symptoms: e.) Objective findings (including current x-rays, EKGs, laboratory data and clinical findings): - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - -

III. TREATMENT 1 a.) Date of first visit (month, day, year):

b.) Date of last visit (month, day, year):

c.) Frequency of treatment: Weekly____________; Monthly_______________; Other (specify)__________ d.) Nature of treatment (including surgery and medications prescribed, if any):

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III. TREATMENT (Continued) e.) Has the patient been hospital confined? (If Yes give name and address of hospital) Yes No ------------------------------------------------------------------------------------------------------------------------------------------------------------------f.) Dates confined from/ through: IV. PHYSICAL IMPAIRMENT (* as defined in federal dictionary of occupational titles) Class 1- No limitation of functional capacity; capable of heavy work. No restrictions * (0-10%) Class 2- Medium manual activity * (15- 30%) Class 3- Slight limitation of functional capacity; capable of light work * (35- 55%) Class 4- Moderate limitation of functional capacity; capable of clerical / administrative (sedentary) activity * 60- 70%) Class 5- Severe limitation of functional capacity; incapable of minimum (sedentary) activity * (75- 100%) Other limitations: ____________________________________________________________________________________________________________ V. MENTAL / NERVOUS IMPAIRMENT (If applicable) a.) Please define "stress" as it applies to this claimant: b.) What stress and problems in interpersonal relations has claimant had on job? ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Class 1 ­ Patient is able to function under stress and engage in interpersonal relations (no Limitations) Class 2 ­ Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations) Class 3 ­ Patient is able to engage in only limited stress situations and engage in limited interpersonal relations (moderate limitations) Class 4 ­ Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations) Class 5 ­ Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) Other limitations: _________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

VI. WORK STATUS a.) Date patient became totally disabled from this condition: VI. REMARKS (Limitations, therapy, etc.) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I declare that I have examined this report and the statement contained herein is to the best of my knowledge and belief true, correct, and complete. I further understand that a fraudulent misstatement in completing this form would result in a loss of benefits for my patient. Name (Attending Physician) (please print) Address (number and street, city, state, and ZIP code) Signature Date (month, day, year) Degree Telephone number ( ) b.) Anticipate return to work date?