REPORT OF INDEPENDENT HEALTH CARE REVIEWER/REVIEW TEAM

History of present illness

Job description

Past medical history

Physical examination

Review of X-ray and/or other testing

Diagnosis

Causal relationship

Records reviewed

Comparison or records reviewed with your findings

Prognosis

DISABILITY - no disability, partial disability, total disability

(No disability) Able to return to former job without restrictions.

(Partial disability) Able to return to modified job with the following restrictions.

(Total disability) Unable to return to work at this time.

Has MAXIMUM MEDICAL IMPROVEMENT (MMI) been reached - yes or no

If no,

treatment recommendations to reach MMI

and

date expected to reach MMI

If yes, degree of functional impairment according to the latest AMA guidelines.

HAS THE TREATING PHYSICIAN COMPLIED WITH THE MEDICAL ADVISORY BOARD PROTOCOL?

yes or no

If no, explain.

MAB05 (6/92) Informational