39-71-1036. Medical status form. (1) 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.

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(2)The form must contain, at a minimum, the following information:

(a)the worker‘s first and last names and claim number;

(b)the diagnosed condition that is a direct result of the compensable injury or occupational disease;

(c)the treatment plan for the worker;

(d)identification of any medications prescribed for treatment of the worker;

(e)the timeframe during which the treating physician recommends that the worker be completely off work;

(f)the date or anticipated date of the worker’s release to modified duty;

(g)the date or anticipated date of the worker’s release to full duty;

(h)any temporary work restrictions applicable to the worker;

(i)any permanent work restrictions applicable to the worker;

(j)the anticipated date of maximum medical improvement; and

(k)the date of the worker’s next appointment.

(3)An insurer may request additional information from the health care provider not contained in the department’s form.

(4)The treating physician or a designee shall complete the form following every office visit with the worker.