The C-4 initial treatment report, the D-39 progress report and disability certification, therapy requests and the police and firefighter exam series, with who completes each.
Nevada's Division of Industrial Relations (DIR) prescribes the forms providers use for a work injury. The Employee's Claim for Compensation/Report of Initial Treatment (C-4) combines the worker's claim with the provider's report of the first visit. Follow-up visits go on the D-39, the Physician's and Chiropractic Physician's Progress Report and Certification of Disability, which certifies temporary total disability or release to full or restricted duty. Requests for more treatment use the D-32 (chiropractic) and D-33 (physical therapy).
On the C-4, the employee completes the top half, and the treating physician, chiropractic physician, PA-C or APRN completes the Report of Initial Treatment below it, then mails it within 3 working days. Copies go to the insurer or TPA, the employer and the employee. Police officers and firefighters have their own exam series: the lung (OD-2), extensive heart (OD-3), limited heart (OD-4) and hearing (OD-5) forms, which the examiner signs and gives to the officer or firefighter.
Combines the injured employee's claim for compensation with the treating provider's report of initial treatment (diagnosis, work status, causation and need for further care).
Records the periodic lung examination (chest X-ray, stethoscopic exam, spirometry) that police officers and firefighters must undergo to keep the lung-disease presumption under NRS 617.455.
Records the extensive heart examination (EKG, stress EKG at 40+, lipids, glucose) required for the heart-disease presumption under NRS 617.457.
Records the limited (interim) heart examination for police officers and firefighters under NAC chapter 617 and NRS 617.457.
Asks the insurer to authorize additional physical therapy treatments, documenting present condition and number of further visits requested.
Progress report that certifies temporary total disability or release to full or restricted duty, with diagnosis, objective findings, ratability and treatment plan.
Asks the insurer to authorize additional chiropractic treatments beyond those already approved, with current findings and expected completion and return-to-work dates.
Records audiometric results and otoscopic exam for police officers and firefighters for occupational hearing-loss purposes.
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At the first visit, the treating physician, chiropractic physician, PA-C or APRN completes the Report of Initial Treatment on the lower half of page 1, and the employee completes the top half. The provider certifies work status, whether the patient will be off work 5 or more days, and whether the job caused the injury, then mails the report within 3 working days of treatment.
After follow-up visits. The treating physician or chiropractic physician uses the D-39 to certify temporary total disability or release to full or restricted duty, with diagnosis, objective findings and treatment plan. Its Stable/Ratable and Discharged boxes trigger claim closure or a permanent partial disability rating. Send it to the insurer or TPA, and to the MCO if there is one.
Use the D-33 for physical therapy and the D-32 for chiropractic. The physical therapist completes the D-33 with the patient's present condition and the number of further visits, and a new prescription from the treating physician must accompany each request. The chiropractor completes the D-32 with current findings and expected completion and return-to-work dates. The insurer marks its decision at the bottom of the form.
Exam forms for police officers and firefighters. The OD-2 records the periodic lung exam that keeps the lung-disease presumption under NRS 617.455, the OD-3 and OD-4 record the extensive and limited heart exams under NRS 617.457, and the OD-5 records hearing results. An audiologist or hearing technician may complete the OD-5. The examiner gives a signed copy to the officer or firefighter, who submits it to the employer.