Sample Questions for Physician

 

Questions:

CE:  Choose from options below or add your own

  1. ImpairmentPlease provide a whole body impairment rating for the accepted conditions listed above in accordance with the 5th edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment with specific page and table references included in your report.  If additional medical records would result in a better evaluation, please so state and identify the needed medical records.  Please provide the rationale and objective findings to support your conclusions.

 

  1. ImpairmentIf it is not possible to complete an impairment rating based on the medical evidence we provided, please advise us what medical records and/or testing is required to complete the rating.

 

  1. DiagnosisIn your opinion, do the medical records support a diagnosis of medical condition?  If so, please provide the first date of diagnosis, diagnosis, and the ICD-9 code.

 

  1. CausationIf medical condition was diagnosed, in your opinion is it at least as likely as not that exposure to toxic substances during the course of employment at covered facility was a significant factor in aggravating, contributing to, or causing the employee’s medical condition?

 

  1. CausationDoes the employee’s work and exposure history make it at least as likely as not that the exposure to the toxic substances was a significant factor in causing, contributing to or aggravating the employee’s medical condition?

 

  1. CausationIf so, please provide the earliest date of diagnosis(es) and ICD-9 code of the condition you believe is related.  Please provide the rationale and objective findings to support your conclusion that the condition(s) are related to the work exposure.

 

 

 

Claims Examiner

Claims Examiner

 

 

 

(Printed Name)

 

 

 

 

 

Date

 

(Signature)

 

(Date)