Form WC196 "Rehabilitation Communication Form" - Colorado

What Is Form WC196?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2016;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC196 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC196 "Rehabilitation Communication Form" - Colorado

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
Rehabilitation Communication Form
Patient Name:
Date:
Date of Birth:
Date of Injury:
Diagnosis:
Subjective:
Patient reports
% overall improvement and a
better,
worse ability to perform the following job
duties:
The patient
has,
has not been compliant with rehabilitation visits and has given
minimal,
moderate,
maximal effort during rehabilitation. Patient has missed
visit(s) in rehabilitation.
Objective:
Initial Evaluation Measurements
[Date]
[Date]
[Date]
°
°
°
°
[Joint Motion (ie. Shoulder Flexion)]
°
°
°
°
[Joint Motion]
°
°
°
°
[Joint Motion]
°
°
°
°
[Joint Motion]
°
°
°
°
[Joint Motion]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle (ie. Shoulder Flexion)]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
[Score]
[Score]
[Score]
[Score]
[Name of Functional Outcomes Tool (ie. Oswestry)]
Other objective findings:
WC 196 Rev 9/16
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
Rehabilitation Communication Form
Patient Name:
Date:
Date of Birth:
Date of Injury:
Diagnosis:
Subjective:
Patient reports
% overall improvement and a
better,
worse ability to perform the following job
duties:
The patient
has,
has not been compliant with rehabilitation visits and has given
minimal,
moderate,
maximal effort during rehabilitation. Patient has missed
visit(s) in rehabilitation.
Objective:
Initial Evaluation Measurements
[Date]
[Date]
[Date]
°
°
°
°
[Joint Motion (ie. Shoulder Flexion)]
°
°
°
°
[Joint Motion]
°
°
°
°
[Joint Motion]
°
°
°
°
[Joint Motion]
°
°
°
°
[Joint Motion]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle (ie. Shoulder Flexion)]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
/ 5
/ 5
/ 5
/ 5
[Motion or Muscle]
[Score]
[Score]
[Score]
[Score]
[Name of Functional Outcomes Tool (ie. Oswestry)]
Other objective findings:
WC 196 Rev 9/16
Patient was given the
scoring
, which shows
low,
medium,
[Name of Functional Outcomes Tool]
high functional ability.
We discussed results of the
and the patient understands we will be following their functional
[Name of Functional Outcomes Tool]
progress using the
. We discussed an appropriate progression in function and then
[Name of Functional Outcomes Tool]
we created functional goals. We will continue to monitor the patient’s function, and progress the plan of care using
the
. The patient and I agreed on the following functional goals:
[Name of Functional Outcomes Tool]
(specific, functional, measurable, time frame)
1)
(% achieved
)
2)
(% achieved
)
3)
(% achieved
)
4)
(% achieved
)
Assessment:
Plan:
PT or OT Signature:
Date:
WC 196 Rev 9/16
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