"Medical Status Form" - Montana

Medical Status Form is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on December 1, 2013;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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MEDICAL STATUS FORM
Employer
Contact
Information
(Optional)
Employee’s Name
Provider
Date of Birth
(Last, First)
Timestamp
(mm/dd/yyyy)
Provider
Date of Injury
Contact
Claim Number
(mm/dd/yyyy)
Information
?
Employee Released to Full Duty
Date
To
Employee Released to Modified Duty (See Work Abilities)
Date
To
Employee May Work Limited Hours:
Hours Per Day
Date
To
Employee May Work Part-time:
To
Date
Employee Not Released to Work
To
Date
Capacity Duration (Estimate Days):
1-10
11-20
21-30
30+
Permanent
?
Continuous
Frequent
Occasional
Never
Blank Space = Not Restricted (NR)
L
R
B
Hand/Wrist
Grasping
L
B
R
B
Pushing/Pulling
L
R
Fine Manipulation
R
B
L
L,
Reaching
R
L
B
Bending
Climbing
Lifting 01-10 lbs.
Lifting 11-20 lbs.
Lifting 21-25 lbs.
Lifting 26-50 lbs.
Lifting 51-70 lbs.
Number of Hours Employee May:
Sit
Stand
Walk
List Other Restrictions:
?
Employee
Date
Signature
Provider
Date
Signature
?
Copy of Medical Status Form to Employee
Date of Next Visit
Employee Progress:
As Expected/Better Than
Treatment Concluded by Provider:
Expected Slower Than Expected
Max. Medical Improvement (MMI):
Current Rehab:
PT OT Home Exercise
Other:
Care Transferred To:
Surgery:
Not Indicated
Consultation Needed With:
Possible
Study Pending:
Planned
Comments:
Medications:
Opioids Prescribed for:
Acute Pain
Chronic Pain
Diagnosis:
?
Revised 12/2013
Medical Provider/Employee Copy
MEDICAL STATUS FORM
Employer
Contact
Information
(Optional)
Employee’s Name
Provider
Date of Birth
(Last, First)
Timestamp
(mm/dd/yyyy)
Provider
Date of Injury
Contact
Claim Number
(mm/dd/yyyy)
Information
?
Employee Released to Full Duty
Date
To
Employee Released to Modified Duty (See Work Abilities)
Date
To
Employee May Work Limited Hours:
Hours Per Day
Date
To
Employee May Work Part-time:
To
Date
Employee Not Released to Work
To
Date
Capacity Duration (Estimate Days):
1-10
11-20
21-30
30+
Permanent
?
Continuous
Frequent
Occasional
Never
Blank Space = Not Restricted (NR)
L
R
B
Hand/Wrist
Grasping
L
B
R
B
Pushing/Pulling
L
R
Fine Manipulation
R
B
L
L,
Reaching
R
L
B
Bending
Climbing
Lifting 01-10 lbs.
Lifting 11-20 lbs.
Lifting 21-25 lbs.
Lifting 26-50 lbs.
Lifting 51-70 lbs.
Number of Hours Employee May:
Sit
Stand
Walk
List Other Restrictions:
?
Employee
Date
Signature
Provider
Date
Signature
?
Copy of Medical Status Form to Employee
Date of Next Visit
Employee Progress:
As Expected/Better Than
Treatment Concluded by Provider:
Expected Slower Than Expected
Max. Medical Improvement (MMI):
Current Rehab:
PT OT Home Exercise
Other:
Care Transferred To:
Surgery:
Not Indicated
Consultation Needed With:
Possible
Study Pending:
Planned
Comments:
Medications:
Opioids Prescribed for:
Acute Pain
Chronic Pain
Diagnosis:
?
Revised 12/2013
Medical Provider/Employee Copy
MEDICAL STATUS FORM
Employer
Contact
Information
(Optional)
Employee’s Name
Provider
Date of Birth
(Last, First)
(mm/dd/yyyy)
Timestamp
Provider
Date of Injury
Contact
Claim Number
(mm/dd/yyyy)
Information
?
Employee Released to Full Duty
Date
To
Employee Released to Modified Duty (See Work Abilities)
Date
To
Employee May Work Limited Hours:
Hours Per Day
Date
To
Employee May Work Part-time:
To
Date
Employee Not Released to Work
To
Date
Capacity Duration (Estimate Days):
1-10
11-20
21-30
30+
Permanent
?
Continuous
Frequent
Occasional
Never
Blank Space = Not Restricted (NR)
L
R
B
Hand/Wrist
Grasping
R
B
L
Pushing/Pulling
L
R
B
Fine Manipulation
L
R
B
Reaching
L
R
B
Bending
Climbing
Lifting 01-10 lbs.
Lifting 11-20 lbs.
Lifting 21-25 lbs.
Lifting 26-50 lbs.
Lifting 51-70 lbs.
Number of Hours Employee May:
Sit
Stand
Walk
List Other Restrictions:
?
Employee
Date
Signature
Provider
Date
Signature
?
Copy of Medical Status Form to Employee
Date of Next Visit
As Expected/Better Than
Employee Progress:
Treatment Concluded by provider:
Expected Slower Than Expected
Max. Medical Improvement
Current Rehab:
PT OT Home Exercise
Other:
(MMI): Care Transferred To:
Surgery:
Not Indicated
Consultation Needed With:
Possible
Study Pending:
Planned
Comments:
Medications:
Opioids Prescribed for:
Acute Pain
Chronic Pain
Diagnosis:
?
Revised 12/2013
Insurer Copy
MEDICAL STATUS FORM
Employer
Contact
Information
(Optional)
Employee’s Name
Provider
Date of Birth
(Last, First)
(mm/dd/yyyy)
Timestamp
Provider
Date of Injury
Contact
Claim Number
(mm/dd/yyyy)
Information
?
Employee Released to Full Duty
Date
To
Employee Released to Modified Duty (See Work Abilities)
Date
To
Employee May Work Limited Hours:
Hours Per Day
Date
To
Employee May Work Part-time:
To
Date
Employee Not Released to Work
To
Date
Capacity Duration (Estimate Days):
1-10
11-20
21-30
30+
Permanent
?
Continuous
Frequent
Occasional
Never
Blank Space = Not Restricted (NR)
L
R
Hand/Wrist
B
Grasping
L
B
R
L
R
Pushing/Pulling
B
L
R
B
Fine Manipulation
L
Reaching
R
B
Bending
Climbing
Lifting 01-10 lbs.
Lifting 11-20 lbs.
Lifting 21-25 lbs.
Lifting 26-50 lbs.
Lifting 51-70 lbs.
Number of Hours Employee May:
Sit
Stand
Walk
List Other Restrictions:
?
Employee
Date
Signature
Provider
Date
Signature
?
Copy of Medical Status Form to Employee
Date of Next Visit
Revised 12/2013
Employer Copy
Medical Status Form Instructions
The purpose of the Medical Status Form is to:
1)
facilitate communication between a worker with a work-related injury or occupational disease, the employer, and the health care
provider for Stay at Work/Return to Work; and
2)
provide necessary medical status to the insurer.
The Medical Status Form is a statutory requirement. MCA 39-71-1036 says, "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." An insurer may request additional information not
contained in the form from the health care provider. The treating physician (or a designee) is now required to complete the form following every office
visit with the worker.
This three-part form is designed to transmit the correct and essential information to the appropriate parties, easily and accurately.
Employer Contact Information: Enter the name, address, phone number and facsimile number of the Employer. (Optional)
Employee Info: Enter Patient/Employee Name, Date of Birth, Claim Number and Date of Injury.
Provider Time Stamp: Health Care Provider may enter timestamp if necessary.
Provider Contact Information: Enter the name, address, phone number and facsimile number for the Provider.
Released for Work? The Medical Status Form will allow for more than one option to be selected. Check all the applicable boxes and enter the
effective date, which in most cases is the date of current office visit. The “To” box is in most cases is the follow-up visit date and can be
considered the “Anticipated MMI date” by the payer. See below for steps for each option.
Patient/Employee Released to Full Duty: If selected, enter the effective date, and skip to Signature and Treatment Plan.
Patient/Employee Released to Modified Duty: If selected, enter the effective date, answer the Capacity Duration (estimate days) and continue
to the next section (Modified Work Abilities).
Patient/Employee Released to Limited Hours: If selected, enter the number of hours per day, enter the effective date, answer the Capacity
Duration (estimate days) and skip to the questions at the bottom of the next section (Modified Work Abilities).
Patient/Employee Released to Work Part-time: If selected, enter days of the week, enter the effective date, answer the Capacity Duration
(estimate days) and skip to the questions at the bottom of the next section (Modified Work Abilities).
Patient/Employee Not Released to Work: If selected, enter the effective date, answer the Capacity Duration (estimate days) and “To” date. Skip to
Signature and Treatment Plan.
Capacity Duration (estimate days) is the provider's estimation of how long the current work restrictions will last. Are the work restrictions
permanent? The capacity duration can also be used to estimate “Anticipated MMI Date” by the payer.
Modified Work Abilities: This section must be completed if Patient/Employee Released to Modified Duty was checked in the previous section. All
categories should be completed if there are restrictions. If there is no restriction; BLANK SPACE means this area is normal and not restricted.
Work Abilities (Continuous/ Frequent/ Occasional/ Never): Check the appropriate box for each activity. If there is limitation to use just one side or
hand check the appropriate “L” for left, “R” for right or “B” for bilateral box.
Number of Hours (Sit/Stand/Walk): Enter the maximum number of hours for each activity the patient/employee is limited to per day if these hours of
limitations exceed normal break and lunch periods and are not accommodated by normal breaks and lunch periods in an 8-hour day.
List Other Restrictions: Is the patient/employee involved in treatment and/or medication related to the work-related injury/occupational disease
that might affect their ability to work safely in any capacity? --A response is required. Enter in free text area of List Other Restrictions. Will the
patient/employee be required to use any devices or braces? --A response is required. Enter in free text area of List Other Restrictions. Additional
comments specific to patient/employee's work abilities --A response is required. Use the List Other Restrictions area to indicate any unaddressed
limitations, such as driving restrictions.
Signatures: The signature of the patient/employee is for the sole purpose of acknowledging receipt of the information on the form.
Provider Signature to complete and date as indicated. Check box if copy of form is given to employee. Date of Next (scheduled) Visit.
The information above is automatically transferred to the Page Two (yellow copy of triplicate form) and Page Three (pink copy triplicate form)
of the form. Page Three (pink copy) is for employer ONLY. The bottom section on Page One (white copy) and Page Two (yellow copy) contains
confidential information for the medical provider, insurer, and patient/employee only and is NOT given to the employer without the patient/
employee's authorization.
Employee Progress: When slower than expected is checked this communicates to payer that more intervention or assistance may need to be
undertaken to improve employee's progress.
Current Rehab: select appropriate category if applies.
Surgery: select one.
Comments: free text area to communicate further information regarding treatment plan or special circumstances or need for aggressive interventions
to the payer; or Stay At Work/Return to Work.
Treatment concluded by this provider: select if this provider has no further treatments or interventions to offer the Employee. Enter effective date.
Max Medical Improvement (MMI): select if the Employee has reached MMI. Enter effective date.
Care Transferred to: complete if transferred indicating name of provider and specialty.
Consultation needed with: complete if necessary and indicate specialty and/or name of provider.
Study Pending: complete if there are diagnostic studies ordered and awaiting results.
Medications: complete for all medications whether OTC or prescribed for the work injury.
Opioids Prescribed for: indicate if Employee is receiving opioids and whether they are for acute (less than 30 days) pain or for chronic (greater than 30
days) pain.
Diagnosis: Enter the work injury/work disease diagnosed condition(s).
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