Colorado's Rule 16 requires this two-page report from the authorized treating physician on every workers' compensation injury. It is marked initial at the first visit, progress when the condition, diagnosis or treatment changes, and closing at MMI, when a rating is needed or at discharge. It covers diagnosis, treatment plan, work status and restrictions, referrals, MMI, maintenance care and permanent impairment.
The authorized treating physician completes all applicable fields and signs with license number. The injured worker's own description of the accident is recorded at the initial visit.
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Physician's Report of Workers' Compensation Injury
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Initial for the first visit for the described injury. Progress when a change in condition, diagnosis or treatment occurs. Closing when the injured worker is at MMI, needs an impairment rating, or is discharged from care. The exam date is the date of the office visit.
No. The instructions say to complete all applicable fields and attach your narrative report to support the findings; the narrative does not replace the form. When an impairment rating is given, attach the Division's required worksheets and a report describing the rating.
If the injury will cause permanent impairment, a Level II accredited physician must perform the rating. A treating physician without that accreditation marks the box for referral to a Level II physician and lists the referral in item 7b.