1. (1) The department shall create a medical status form to be provided to a health care provider providing treatment for a compensable injury or occupational disease.

2. (2) The form must contain, at a minimum, the following information:

   1. (a) the worker's first and last names and claim number;
   2. (b) the diagnosed condition that is a direct result of the compensable injury or occupational disease;
   3. (c) the treatment plan for the worker;
   4. (d) identification of any medications prescribed for treatment of the worker;
   5. (e) the timeframe during which the treating physician recommends that the worker be completely off work;
   6. (f) the date or anticipated date of the worker's release to modified duty;
   7. (g) the date or anticipated date of the worker's release to full duty;
   8. (h) any temporary work restrictions applicable to the worker;
   9. (i) any permanent work restrictions applicable to the worker;
   10. (j) the anticipated date of maximum medical improvement; and
   11. (k) the date of the worker's next appointment.
3. (3) An insurer may request additional information from the health care provider not contained in the department's form.
4. (4) The treating physician or a designee shall complete the form following every office visit with the worker.

History: En. Sec. 28, Ch. 167, L. 2011.