• for initial report, include all requirements listed below
• for subsequent reports, include only facts and findings that are new or changed from your last report.

History of the injury/illness

• Who provided you with the information about the injury/illness?
• Describe where and how the injury/illness occurred
• Describe the patient's injury/illness and identify specifically any affected body parts
• Other treatment for the injury/illness including hospitalization or surgery
• Patient's subjective complaints
• Relevant medical history, incl. prior treatment for a similar work-related injury/illness

Objective Findings/Clinical Evaluation

• Physical examination (describe all relevant findings)
• Diagnostic procedure(s)/test(s) performed prior to the visit
• Diagnostic procedure(s)/test(s) performed during the visit
• Treatment rendered at time of exam, if any
• Diagnosis/clinical assessments

Plan of Care

• Proposed treatment and treatment goals (include type of treatment, frequency and anticipated duration of treatment)
• Medications (prescription and over-the-counter drugs) prescribed for the injury/illness
• Any work restrictions that may result from these medications
• Diagnostic test(s) ordered
• Referrals/Consultations requested
• Assistive devices prescribed
• Prognosis for recovery
• Follow-up appointment(s)

Work Status

• Can the patient return to usual work activities as indicated (A.11)?
• Are there any work limitations? (If so, explain and quantify, including the anticipated duration of the limitations)
• Describe discussions with the patient and employer regarding return to work with any applicable limitations

Impairment
(Comment only if patient has a temporary impairment as indicated in E.4)

• Describe findings and explain how impairment percentage was determined

Attachment File Types Accepted for Web Submission:

• Text files (.txt file extension)
• MS Word files (.doc file extension)
• Rich Text files (.rtf file extension)
• Tiff files preferably with a resolution of 200 dpi (.tif or .tiff file extension)
• JPEG files (.jpg file extension)
• GIF files (.gif file extension)
• BMP files (.bmp file extension)
• PDF files (.pdf file extension)

Attachment File Types Accepted for XML Submission:

• Text (included in XML file)
• Tiff files with a resolution of 200 dpi (.tif or .tiff file extension)