Fill out the form in our online filing application The goal is to align the information collected with this objective. Providers must submit this form or their own equivalent document whenever they see an injured worker When submitting such a report, the document must contain the data elements required on this form at a minimum. Please complete this form and provide a copy to the worker during the worker’s office visit Use this form to provide detailed information about the injured worker’s ability to work
Add comments to section 4 or attach additional information as necessary. Bwc uses the information to support a request for temporary total compens the treating physician must submit this form each time they see the injured worker unless they Have been awarded permanent and total disability Have returned to work without restrictions within seven days of the injury.
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