Montana Code 39-71-1036. Medical status form
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.
Terms Used In Montana Code 39-71-1036
- worker: means :
(a)each person in this state, including a contractor other than an independent contractor, who is in the service of an employer, as defined by 39-71-117, under any appointment or contract of hire, expressed or implied, oral or written. See Montana Code 39-71-118
(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.