WORK STATUS REPORT/MEDICAL SERVICE FORM

COMMUNITY INSURANCE CORPORATION

18550 W CAPITOL DRIVE

BROOKFIELD, WI 53045

800-236-6885 (PROVIDER LINE)

Custodians/Trades fax to 608-204-0374 immediately All other units fax to 608-442-2169 immediately

EMPLOYER HAS LIGHT DUTY ASSIGNMENTS AVAILABLE

EMPLOYER INFORMATION
Madison Metropolitan School District / 545 W Dayton St, Room 133, Madison, WI 53703 / Phone: 608-663-5930
EMPLOYEE INFORMATION (to be completed by the employee)
Name / Date of Birth / // / SSN (required) / --
Home/Cell Phone / () - / B#
Date of Injury / // / Time of Injury / : AM PM

Employee: To expedite prompt claim handling, this complete form is to be returned to your employer either on the same day of the appointment or, should lost time be incurred, it is to be forwarded to your employer the day following the appointment. Be sure to give this form to your supervisor and request that the supervisor forward the paperwork on to the appropriate departments

MEDICAL INFORMATION (to be completed by the treating licensed physician/medical doctor)
Employee to receive treatment at: / Clinic Urgent Care Emergency Room
Date of Exam: / // / Time of Exam: / : AM PM / Date of Follow Up Appointment: / //
Diagnosis:
Treatment Plan: / Must return for re-evaluation on //
To receive PT/OT services at the rate of time per week for weeks
Inpatient surgery schedule on // at : AM PM
Outpatient surgery schedule on // at : AM PM
Expected Healing Time Days Weeks Months Other ______
No further care required – Discharge date //
Current Work Status: / May work full duty now (no restrictions) – date //
Presently working as of //
May not work full or light duty (off work) until //
May work light duty now with identified restrictions through //
Lifting Pushing Pulling
Maximum weight in pounds for above three functions: 0 10 20 30 40 50 60
Bending
Maximum number of bends per hour: 0-2 2-6 6-10 10-20
Degree of bend allowable: 10-20 20-45 Full
No Standing
No Sitting
No Walking
Keep dressing/wound clean and dry
Medication may cause drowsiness. Use caution when operating machinery or equipment.
Comments:
Physician Name: / Physician Signature:
Facility Name & Address: / Phone Number: / () -
ALL TIME AWAY FROM WORK (including any related appointments ) AND NOTICE OF RESTRICTIONS MUST BE DOCUMENTED IN WRITING BY A LICENSED PHYSICIAN/MEDICAL DOCTOR. NOTES FROM A NURSE PRACTITIONER (APNP) OR PHYSICIAN’S ASSITANT (PA-C) WILL NOT BE ACCEPTED. NOTES MUST BE SIGNED BY A LICENSED PHYSICIAN/MEDICAL DOCTOR.