INITIAL MEDICAL DOCUMENTATION

Traumatic Injury (CA-1)

Medical documentation is critical for whatever type of injury or illness you are claiming to be work related. When making a claim for workers’ compensation, your physician will be required to submit a narrative statement in support of your claim. This report should include:

• Carrier’s name and address; and OWCP file number (if one has been assigned)
• History of occupational disease. This is a key item and should consist of a written statement by the physician reflecting knowledge of the conditions of the patient’s employment believed to be the causative factors. It is suggested that the physician first be furnished with your written statement. The physician should ideally include or attach a copy of the statement referencing it with remarks similar to the following: "I have read the statement date…prepared by…regarding the conditions of employment at…during the period from…to…
• Dates of examinations and/or treatment (past and present)
• Periods of hospitalization, if any
• Tests given, findings and results (x-rays, lab tests, EKG, MRI, etc.…)
• Definitive diagnosis (no impressions)
• Opinion: was condition caused, permanently or temporarily aggravated, accelerated, or precipitated (hastened) by conditions of employment described by the patient?
• Medical reasons for opinion (i.e., how did the physician, from a medical point of view, arrive at the opinion?). This is very important and it should be as specific as possible and include how any test results helped form a basis for the opinion.
• Statement describing any concurrent medical conditions unrelated to the injury or Occupational Disease.
• Period(s) of disability and the extent of disability during the period(s). This should specify whether the disability is total or partial; and if partial, the work limitations in working while partially disabled. The work limitations should describe the restrictions and include the number of hours allowed for each function per day. Disability from any apparent concurrent medical conditions unrelated to the Occupational disease must be considered in determining the employee’s ability to work; and an explanation included describing how any unrelated injuries affects the employee’s ability to work. OWCP-5a, 5b, or 5c may be used for establishing work tolerance limitations.
• Statement concerning whether maximum medical improvement has been reached; and if so, the nature and extent of any remaining disability.
• Signature of physician (show specialty and Board Certifications); and date.

(Please note that each of the above items may not apply to each type of injury or illness claimed. These items are provided only as a guideline for your physician to follow.)

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