Skip to Content

Workers’ Compensation Board

If you are using an Internet Explorer 11 web browser and are having trouble logging into any of the Board's web applications, please refer to these instructions. Login Problems and IE 11

CMS-1500 Ophthalmology Narrative Report

Ophthalmology Narrative Report

The Ophthalmology Narrative should include the following information:

  • Rendering Provider's Name


  • How did the injury occur?
  • If there are any pre-existing ocular conditions, describe specifically.
  • Describe nature and extent of injury, including permanent ocular defects, and/or permanent facial, head or neck disfigurement, if any, due to present injury.
  • If the patient was hospitalized, give name/location of hospital and dates of hospitalization.
  • Has the patient missed work because of the injury/illness? If yes, provide the date the patient first missed work?
  • Is the patient working? If yes, provide the date(s) the patient:
    • Resumed limited work of any kind
    • Resumed full work

Temporary Impairment

  • What is the percentage (0-100%) of temporary impairment?
  • Describe findings and explain how impairment percentage was determined.

Causal Relationship:

  • Was the occurrence described above (or in your previous report) the competent producing cause of the injury or disability (if any) sustained?

Physical Examination

  • Attach visual field test, diagram site of injury, if applicable.
  • Present condition:
    • Document corrected and uncorrected vision in each eye and all other permanent defects (all permanent defects must be known in order to determine compensation due).
  • Results of interval diagnostic test, imaging studies and/or procedures performed
  • Diagnostic procedure(s)/test(s) performed during the visit
  • Treatment rendered at time of exam, if any


  • Clear identification of diagnosis(es), including differential diagnosis (i.e., not a listing of ICD or CPT billing codes)

Treatment Plan/Recommendations:

  • Proposed treatment and treatment goals (include type of treatment, frequency, anticipated duration of treatment and re-evaluation timeframe)
  • Medication (prescription and over-the-counter drugs) prescribed for the injury/illness:
    • Name, dose, frequency
    • Identify discontinued medication(s) and/or changed dosage(s), including
    • reason(s) for any changes
    • Any work restrictions that may result from these medications
  • Diagnostic test(s) ordered and indication(s)
  • Referrals/consultations requested and indication(s)
  • Follow-up appointment(s)