Sample Questions for
Physician
Questions:
CE: Choose
from options below or add your own
- 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.
- 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.
- 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.
- 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?
- 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?
- 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.
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Claims Examiner
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Claims Examiner
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(Printed Name)
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Date
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(Signature)
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(Date)
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