Form 618136 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Claimant Name and Date of Birth in the designated fields. This information is crucial for identifying the patient.
3. Fill in the primary diagnosis and ICD-9 code. Ensure accuracy as this will impact the claim evaluation.
4. Indicate whether the condition is work-related by selecting 'Yes' or 'No'. If applicable, provide the Date of Injury/Illness.
5. Detail any additional factors impacting return to work in the provided section.
6. Complete treatment history by noting when you first treated the patient for this impairment episode and if there were prior treatments.
7. List current medications related to this impairment, including dosage and frequency, in the appropriate field.
8. Specify any restrictions placed on your patient both at work and at home, ensuring clarity for future accommodations.
9. Finally, fill out your details including Physician Name, Degree & Specialty, Address, Telephone Number, and sign where indicated.

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