Treating doctors use the C3 Capability Assessment to tell North Dakota Workforce Safety & Insurance what an injured worker can do after a visit. It records the ICD-10 diagnosis, whether the worker is released with or without restrictions, a grid of physical capabilities by frequency with lifting limits, the follow-up plan, and whether the worker has reached maximum medical improvement or is likely to have permanent partial impairment.
The physician completes Sections 2 to 5 and signs Section 6 with facility and telephone, and Section 1 claim information is required. The injured employee also signs Section 6, acknowledging the fraud warning and the release of information on the back.
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Capability Assessment
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The C3 Capability Assessment documents a doctor's assessment of an injured worker on a North Dakota claim: the diagnosis and purpose of the visit (initial evaluation, re-check or discharge), work release, physical capabilities and restrictions, follow-up plan, and MMI and permanent partial impairment status. WSI asks that it be returned immediately.
Yes. Section 6 has signature lines for both the physician and the injured employee. The employee's signature acknowledges the fraud warning and the release of information, which authorizes providers to respond to WSI, including conclusions and opinions not otherwise contained in the medical records.
Section 1 claim information is required, and the form states that disclosure of the Social Security number is mandatory under N.D.C.C. 65-05-02 for identification and verification. Leaving it off may delay processing of the form.