After an impairment rating evaluation (IRE) under Section 306(a.3) of the Pennsylvania Workers' Compensation Act, the examining physician reports the result on this face sheet. It states the whole-person impairment percentage, attaches the report prepared under the AMA Guides, 6th edition, and certifies the physician's qualifications. The insurer can then use the rating, through its own Notice of Change of Disability Status (LIBC-764), to address the employee's disability status.
The examining physician completes the face sheet, including the attestation, impairment percentage, exam date and charge. Page one carries claim party details for the employee, attorneys, employer, insurer and claim representative.
Download the current version from the source each time; forms change without notice.
Impairment Rating Determination Face Sheet
Pennsylvania Department of Labor & Industry, Bureau of Workers' Compensation takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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The signing physician attests to being a physician in Pennsylvania certified by an American Board of Medical Specialties approved board or its osteopathic equivalent, with an active clinical practice of at least twenty hours per week. The evaluation is performed by a Bureau-designated IRE physician who meets those requirements.
The face sheet states that the original face sheet and report go to the Bureau of Workers' Compensation, Healthcare Services Review Division, with copies to the employee, the employee's attorney if known, and the insurer, within 30 days of the date of the impairment evaluation.