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Click ‘Get Form’ to open the D-39 Form in the editor.
Begin by entering the Claim Number and Social Security Number at the top of the form. This information is crucial for identifying the patient’s case.
Fill in the Patient’s Name, Date of Injury, and Employer details. Ensure accuracy as this data is essential for processing.
If applicable, provide the name of the Managed Care Organization (MCO) and describe the Patient’s Job Description/Occupation.
Detail any Previous Injuries, Diseases, or Surgeries that may contribute to the current condition. This section helps in understanding medical history.
State the Diagnosis and indicate if it relates to an Industrial Injury. Use the provided fields to explain further if necessary.
Document Objective Medical Findings by selecting from options like 'Stable' or 'Condition Worsened'.
Outline the Treatment Plan by checking relevant boxes such as 'PT/OT Prescribed' or 'Released to FULL DUTY'.
Finally, enter your name and signature as a Physician/Chiropractor at the bottom of the form before saving or sharing it.

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