Form WC-2 Physician's Report - Hawaii

Form WC-2 is a Hawaii Department of Labor & Industrial Relations form also known as the "Physician's Report". The latest edition of the form was released in October 1, 2005 and is available for digital filing.

Download an up-to-date Form WC-2 in PDF-format down below or look it up on the Hawaii Department of Labor & Industrial Relations Forms website.

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STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR FORM WC-2 PHYSICIAN'S REPORT
Instructions
Please completely fill out the WC-2 PHYSICIAN'S REPORT FORM.
The Delivery Information section below lists various delivery options. Please select the most convenient method and
submit the completed form accordingly.
Please remember to sign and date the form before submitting it.
Delivery Information
Delivery by U.S. Mail, In-Person, or via Fax
Oahu
Kauai
Maui
Princess Keelikolani Building
3060 Eiwa Street, Room 202
2264 Aupuni Street #2
830 Punchbowl Street, Room 209
Lihue, Hawaii 96766
Wailuku, Hawaii 96793
Honolulu, Hawaii 96813
Phone: (808) 274-3351
Phone: (808) 984-2072
Mailing Address:
Fax: (808) 274-3355
Fax: (808) 984-2071
P.O. Box 3769
Honolulu, Hawaii 96812-3769
Phone: (808) 586-9161
Fax: (808) 586-9219
Hawaii
West Hawaii
75 Aupuni Street, Room 108
Ashikawa Building
Hilo, Hawaii 96720
81-990 Halekii Street, Room 2087
Kealakekua, Hawaii 96750
Phone: (808) 974-6464
Fax: (808) 974-6460
If Mailing, Please Mail to This Address:
P.O. Box 49, Kealakelua, Hawaii 96750
Phone: (808) 322-4808
Fax: (808) 322-4813
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 9/05)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR FORM WC-2 PHYSICIAN'S REPORT
Instructions
Please completely fill out the WC-2 PHYSICIAN'S REPORT FORM.
The Delivery Information section below lists various delivery options. Please select the most convenient method and
submit the completed form accordingly.
Please remember to sign and date the form before submitting it.
Delivery Information
Delivery by U.S. Mail, In-Person, or via Fax
Oahu
Kauai
Maui
Princess Keelikolani Building
3060 Eiwa Street, Room 202
2264 Aupuni Street #2
830 Punchbowl Street, Room 209
Lihue, Hawaii 96766
Wailuku, Hawaii 96793
Honolulu, Hawaii 96813
Phone: (808) 274-3351
Phone: (808) 984-2072
Mailing Address:
Fax: (808) 274-3355
Fax: (808) 984-2071
P.O. Box 3769
Honolulu, Hawaii 96812-3769
Phone: (808) 586-9161
Fax: (808) 586-9219
Hawaii
West Hawaii
75 Aupuni Street, Room 108
Ashikawa Building
Hilo, Hawaii 96720
81-990 Halekii Street, Room 2087
Kealakekua, Hawaii 96750
Phone: (808) 974-6464
Fax: (808) 974-6460
If Mailing, Please Mail to This Address:
P.O. Box 49, Kealakelua, Hawaii 96750
Phone: (808) 322-4808
Fax: (808) 322-4813
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 9/05)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
FORM WC-2 PHYSICIAN'S REPORT
Note: PLEASE DO NOT WRITE IN SHADED BLOCKS
1
2
3
4
5
6
Case Number
First
First & Final
Final
Interim
Consulting
Rating
Date this report
received
/
/
Mo.
Day
Yr.
Employer Name and Address
Carrier’s Name and Address
Yes
No
1.
Are you the attending
physician?
2.
Has the patient been burned?
Patient’s Name and Address
Your Name, Address and Telephone No.
3.
Is there a possibility of other
disfigurement?
4.
Do you think physical
rehabilitation will be
necessary?
Patient’s Social Security Number
Physician’s ID
5.
Do you think medical
Date of Injury/Illness
Date of First Treatment
If patient expired, give date
rehabilitation will be
/
/
/
/
/
/
necessary?
Mo.
Day
Yr.
Mo.
Day
Yr.
Mo.
Day
Yr.
State in patient’s own words where and how the accident occurred:
Give accurate description and extent of injury: specify all parts of the body involved and state objective findings.
Is accident mentioned above the only cause of patient’s condition?
Yes
No, state contributing causes.
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
FORM WC-2 PHYSICIAN'S REPORT
Page 2 of 2
Who engaged your services?
Is further treatment required?
No
Yes, period of time required?
Were X-Rays taken?
No
Yes, by whom?
Date(s)
X-Ray Diagnosis:
Was patient treated by anyone else?
No
Yes, by whom?
Date(s)
Was patient hospitalized?
No
Yes, date of admission:
Date of Discharge:
Name and Address of Hospital
Describe subsequent treatment to be provided by you
Did accident result in disability for work?
Yes
No, date disability began:
Patient
was
will be able to resume
light work
regular work on:
Patient stopped treatment without orders on
Patient discharged as cured on
Describe any permanent defect or disfigurement (include scars, discolorations, deformities, etc.)
None
Final Diagnosis:
Physician Signature
Date
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
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