Hawaii attending physicians send this one-page plan to the employer or carrier when treatment goes beyond the initial visits, as HAR 12-15-32 requires. It sets treatment start and end dates, diagnosis, prognosis, modalities and diagnostics, any referral, measurable goals with baselines, the number and frequency of visits, and a total cost estimate. The reviewer marks it approved or denied and returns it.
The attending physician completes and signs everything above the dashed line. The person reviewing for the employer or carrier completes the bottom block, approving or denying with a reason and contact information.
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Hawaii Workers' Compensation Treatment Plan
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Under HAR 12-15-32 the attending physician must submit a treatment plan when treatment goes beyond the initial visits. The plan goes to the employer or carrier, whose reviewer approves or denies it before the treatment proceeds, giving a reason for any denial.
The form asks for a specific time schedule of measurable objectives with baseline and goal values, such as pain scores, range of motion in named areas, sitting, standing and walking tolerance, and hours of continuous sleep, projected to the end of the treatment plan.