Missouri's Division of Workers' Compensation sends this one-page sheet to an attending physician when its physical rehabilitation staff are deciding whether an injured employee qualifies for physical rehabilitation benefits. The physician answers four yes or no questions on rehabilitation received, current, expected or not indicated, based on the patient's condition at the time of injury or when rehabilitation began.
The attending physician completes the sheet with mailing address and phone. The form also identifies the employee, employer, injury number, insurer's number and the insurer's contact person for the claim.
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Physician's Rehabilitation Information Sheet
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The Division of Workers' Compensation uses it to gather additional information when determining whether an injured employee is eligible for physical rehabilitation benefits. The attending physician confirms whether rehabilitation was received, is underway, is expected, or was neither received nor indicated.
The patient's condition at the time of the injury or when rehabilitation began. The form points out that this may differ from the patient's present condition, so the answers describe that earlier point even if the patient has changed since.