In a California workers' compensation claim, the primary treating physician uses this two-sheet report to update the claims administrator on subjective complaints, objective findings, ICD-10 diagnoses, the treatment plan and work status. Under 8 CCR 9785(f) it is due when the condition, treatment plan or work status changes, on release from care, and at least every 45 days during continuing treatment. It often travels with a DWC Form RFA as the supporting report.
The primary treating physician (PTP) completes the whole form and signs it with an original signature, not a stamp, under a declaration of penalty of perjury. Secondary physicians report to the PTP, who must incorporate or comment on their reports in the PTP's own report; the patient and employer complete no part of it.
Check every box that explains why the report is going out now: periodic report (required 45 days after the last report), change in treatment plan, release from care, change in work status, need for referral or consultation, response to request for information, change in patient's condition, need for surgery or hospitalization, request for authorization, or other. These boxes tell the claims administrator which 8 CCR 9785(f) trigger applies. Check Additional pages attached when you append a narrative or extra sheets.
Enter the patient's last name, first name, middle initial, street address or PO box, city, state, ZIP code, sex, date of birth, occupation and phone number. These fields let the claims administrator match the report to the right injured worker, so keep them consistent with the Doctor's First Report (Form 5021) and earlier progress reports on the same claim.
Record the date of injury, the claims administrator's name, claim number, address, phone and fax, and the employer's name and phone. The claim number is what ties the report to the file, so copy it from the claims administrator's correspondence. The same identifiers appear on any DWC Form RFA you attach this report to.
The form states this information must be provided, on the form or in a substituted or appended narrative. Summarize the patient's current symptoms and how they have changed since the last report. Reviewers read the complaints against the objective findings and work status that follow to judge whether the treatment plan and restrictions are supported.
Include significant physical examination, laboratory, imaging or other diagnostic findings. Measurable findings from this visit give the claims administrator, and any utilization reviewer looking at an attached request for authorization, the clinical basis for continued treatment, a referral, or a change in work status.
List up to twelve diagnoses, each with its ICD-10 code. Use the conditions treated as part of the work injury, and keep the codes consistent with any DWC Form RFA that relies on this report, since the RFA requires a diagnosis and ICD code for every requested service.
Include treatment rendered to date, then list methods, frequency and duration of planned treatment. Specify any consultation or referral, surgery and hospitalization, and identify each physician and non-physician provider. For physical medicine such as physical therapy, manipulation or acupuncture, give the type, frequency and duration. CPT codes are encouraged. State whether the treatment plan has changed and, if so, why.
Choose one instruction: remain off work until a date; return to modified work on a date with limitations or restrictions, listing every specific restriction such as standing, sitting, bending or use of hands; or return to full duty on a date with no limitations or restrictions. Employers and claims administrators act on these dates, so give an exact date for each choice.
Enter the date of exam, sign with an original signature (the form says do not stamp), and add the California license number, where the report was executed, the date in mm/dd/yyyy, physician name, specialty, address and phone. Signing declares under penalty of perjury that the report is true and correct and that you have not violated Labor Code section 139.3.
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Primary Treating Physician's Progress Report (PR-2)
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Sources for this guide
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Under 8 CCR 9785(f), the primary treating physician reports when the patient's condition changes unexpectedly, the treatment plan changes significantly, work status changes, the patient is released from care, or permanent disability is likely to preclude the usual occupation. While treatment continues, a report is due no later than 45 days after the last report of any type, even without a trigger.
Yes. A narrative is accepted if it is titled Primary Treating Physician's Progress Report in bold type, states the reason it is being submitted, and uses the same information, subject headings and order as the PR-2. It must also include the same declaration under penalty of perjury, including the Labor Code section 139.3 statement. By mutual agreement, physician and claims administrator may use another format.
The primary treating physician signs it with an original signature rather than a stamp and adds the California license number, specialty, place executed and date. The signature sits under a declaration that the report is true and correct to the best of the physician's knowledge and that the physician has not violated Labor Code section 139.3.
Once the patient is permanent and stationary, meaning maximum medical improvement, the PR-2 no longer applies. The PTP then reports permanent impairment, limitations and future medical care within 20 days of the exam on Form PR-3 or PR-4, or an equivalent narrative. The PR-4 is the version used for ratings under the AMA Guides, 5th Edition.