1. (a) A doctor who is required to certify, or who determines during the course of treatment, whether an employee has reached maximum medical improvement, or has an impairment, shall complete and file a medical evaluation report as required by this rule.

2. (b) Certification, or to certify, in these rules, means the formal assertion of medical facts or expert opinion by a doctor supporting or relating to:

   1. (1) whether an employee has or has not reached maximum medical improvement; or
   2. (2) whether an employee has any impairment, and, if so, the employee's impairment rating.

3. (c) All reports made under this rule shall be on a form prescribed by the commission and shall contain:

   1. (1) the workers' compensation number assigned to the claim by the commission;
   2. (2) the employee's name and social security number;
   3. (3) the date of injury;
   4. (4) the doctor's name, address, professional license number, federal tax identification number, and signature;

   5. (5) a narrative history of the employee's medical condition(s), including, but not limited to:

      1. (A) onset and course of the employee's medical condition(s); and
      2. (B) findings of previous examinations, treatments, and responses to treatments not previously reported to the insurance carrier and the commission by the doctor making the report;
   6. (6) a description of the results of the most recent clinical evaluation of the employee; and
   7. (7) a statement that the employee has reached, or an estimate of when the employee will reach, maximum medical improvement.

4. (d) After the doctor has certified maximum medical improvement and before the doctor assigns an impairment rating, the doctor must:

   1. (1) determine if an objective clinical or laboratory finding of permanent impairment exists; and
   2. (2) document specific laboratory or clinical findings that an impairment exists.
5. (e) If a doctor certifies that an employee has an impairment, the doctor shall assign a whole body impairment rating based on the injury. All certifications of impairment shall be made in compliance with the rating criteria contained in the second printing, dated February 1989, of the American Medical Association's Guides to the Evaluation of Permanent Impairment, third edition (the Guides).
6. (f) A doctor required to submit a report under this chapter shall submit supplementary and explanatory reports and information as requested by the commission or the carrier.

7. (g) The medical evaluation report form shall contain:

   1. (1) the information required in subsection (c) of this section;
   2. (2) an instruction to the doctor that the impairment rating shall be based on the compensable injury alone; and
   3. (3) an instruction to the doctor as to the definition of objective clinical or laboratory finding as contained in the Texas Workers' Compensation Act, §1.03.
8. (h) A report required under this rule shall be filed with the commission, employee, and insurance carrier no later than seven days after the examination.

Source Note:The provisions of this §130.1 adopted to be effective January 24, 1991, 16 TexReg 176.