STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
This form is required to be used for ratings prepared pursuant to the 2005 Permanent Disability Rating Schedule and the AMA Guides to the Evaluation of Permanent Impairment (5th Ed.). It is designed to be used by the primary treating physician to report the initial evaluation of permanent impairment to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient's condition becomes permanent and stationary.
This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation.
Patient:
___________________________
Last Name
______________________________
Middle Initial
_____
First Name
______________________________
Sex
_____
Date of Birth
___________________________
Address
__________________________________________________
City
________________________________________
State
____________________
Zip
___________________________
Occupation
________________________________________
Social Security Number
________________________________________
Phone No.
Claims Administrator/Insurer:
___________________________
Name
______________________________________________________________________
Phone Number
___________________________
Address
__________________________________________________
City
________________________________________
State
____________________
Zip
Employer:
___________________________
Name
______________________________________________________________________
Phone Number
___________________________
Address
__________________________________________________
City
________________________________________
State
____________________
Zip
Treating Physician:
___________________________
Name
______________________________________________________________________
Phone Number
___________________________
Address
__________________________________________________
City
________________________________________
State
____________________
Zip
___________________________
You must address each of the issues below. You may substitute or append a narrative report if you require additional space to adequately report on these issues.
___________________________
Date of Injury ____________________(Date) Last date worked ____________________(Date) Permanent & Stationary date ____________________(Date) Date of current examination ____________________(Date)
Description of how injury/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos):
Patient's Complaints:STATE OF CALIFORNIADivision of Workers' CompensationPRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
Relevant Medical History:
Objective Findings:
Physical Examination: Describe all relevant findings as required by the AMA Guides, 5th Edition. Include any specific measurements indicating atrophy, range of motion, strength, etc. Include bilateral measurements - injured/uninjured - for injuries of the extremities.
Diagnostic tests results (X-ray/Imaging/Laboratory/etc.)
Diagnoses (List each diagnosis; ICD-9 code must be included) | ICD-9 | ||
___________________________1. | ___________________________ | ||
___________________________2. | ___________________________ | ||
___________________________3. | ___________________________ | ||
___________________________4. | ___________________________ |
Impairment Rating:
Report the whole person impairment (WPI) rating for each impairment using the AMA Guides, 5th Edition, and explain how the rating was derived. List tables used and page numbers.
Impairment | WPI% | Table #(s). | Page #(s) |
Explanation | |||
Impairment | WPI% | Table #(s). | Page #(s) |
Explanation | |||
Impairment | WPI% | Table #(s). | Page #(s) |
Explanation | |||
Impairment | WPI% | Table #(s). | Page #(s) |
Explanation |
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
Pain assessment:
If the burden of the worker's condition has been increased by pain-related impairment in excess of the pain component already incorporated in the WPI rating under Chapters 3-17 of the AMA Guides, 5th Edition, specify the additional whole person impairment rating (up to 3% WPI) attributable to such pain. For excess pain involving multiple impairments, attribute the pain in whole number increments to the appropriate impairments. The sum of all pain impairment ratings may not exceed 3% for a single injury.
Apportionment:
Effective April 19, 2004, apportionment of permanent disability shall be based on causation. Furthermore, any physician who prepares a report addressing permanent disability due to a claimed industrial injury is required to address the issue of causation of the permanent disability, and in order for a permanent disability report to be complete, the report must include an apportionment determination. This determination shall be made pursuant to Labor Code Sections 4663 and 4664, set forth below:
Labor Code section 4663. Apportionment of permanent disability; Causation as basis; Physician's report; Apportionment determination; Disclosure by employee
Labor Code section 4664. Liability of employer for percentage of permanent disability directly caused by injury; Conclusive presumption from prior award of permanent disability; Accumulation of permanent disability awards
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
Yes | No | |
Is the permanent disability directly caused, by an injury or illness arising out of and in the course of employment? | [] | [] |
Is the permanent disability caused, in whole or in part, by other factors besides this industrial injury or illness, including any prior industrial injury or illness? | [] | [] |
If the answer to the second question is "yes," provide below:
STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
Future Medical Treatment: Describe any continuing medical treatment related to this injury that you believe must be provided to the patient. ("Continuing medical treatment" is defined as occurring or presently planned treatment.) And describe any medical treatment the patient may require in the future. ("Future medical treatment" is defined as treatment which is anticipated at some time in the future to cure or relieve the employee from the effects of the injury.) Include medications, surgery, physical medicine services, durable equipment, etc.
Comments:
Functional Capacity Assessment:
Note: The following assessment of functional capacity is to be prepared by the treating physician, solely for the purpose of determining a claimant's ability to return to his or her usual and customary occupation, and will not be considered in the permanent impairment rating.
Limited, but retains MAXIMUM capacities to LIFT (including upward pulling) and/or CARRY:
[ ] 10 lbs. [ ] 20 lbs. [ ] 30 lbs. [ ] 40 lbs. [ ] 50 or more lbs.
FREQUENTLY LIFT and/or CARRY:
[ ] 10 lbs. [ ] 20 lbs. [ ] 30 lbs. [ ] 40 lbs. [ ] 50 or more lbs.
OCCASIONALLY LIFT and/or CARRY:
[ ] 10 lbs. [ ] 20 lbs. [ ] 30 lbs. [ ] 40 lbs. [ ] 50 or more lbs.
STAND and/or WALK a total of:
[ ] Less than 2 HOURS per 8 hour day
[ ] Less than 4 HOURS per 8 hour day
[ ] Less than 6 HOURS per 8 hour day
[ ] Less than 8 HOURS per 8 hour day
SIT a total of:
[ ] Less than 2 HOURS per 8 hour day
[ ] Less than 4 HOURS per 8 hour day
[ ] Less than 6 HOURS per 8 hour day
[ ] Less than 8 HOURS per 8 hour day
PUSH and/or PULL (including hand or foot controls):
[ ] UNLIMITED
[ ] LIMITED (Describe degree of limitation)
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
ACTIVITIES ALLOWED:
Frequently | Occasionally | Never | |
Climbing | [ ] | [ ] | [ ] |
Balancing | [ ] | [ ] | [ ] |
Stooping | [ ] | [ ] | [ ] |
Kneeling | [ ] | [ ] | [ ] |
Crouching | [ ] | [ ] | [ ] |
Crawling | [ ] | [ ] | [ ] |
Twisting | [ ] | [ ] | [ ] |
Reaching | [ ] | [ ] | [ ] |
Handling | [ ] | [ ] | [ ] |
Fingering | [ ] | [ ] | [ ] |
Feeling | [ ] | [ ] | [ ] |
Seeing | [ ] | [ ] | [ ] |
Hearing | [ ] | [ ] | [ ] |
Speaking | [ ] | [ ] | [ ] |
Describe in what ways the impaired activities are limited:
___________________________
___________________________
Environmental restrictions (e.g. heights, machinery, temperature extremes, dust, fumes, humidity, vibration etc.)
Yes | No | |
Can this patient now return to his/her usual occupation? | [] | [] |
List information you reviewed in preparing this report, or relied upon for the formulation of your medical opinions:
Medical Records:
Written Job Description:
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
Other:
___________________________
Primary Treating Physician (original signature, do not stamp)
I declare under penalty of perjury that this report is true and correct to the best of my knowledge, and that I have not violated Labor Code § 139.3.
Signature: ___________________________ | Cal. Lic. #: ___________________________ | |
Executed at: ___________________________ | Date: ___________________________ | |
(County and State) | ||
Name (Printed): ___________________________ | Specialty: ___________________________ |
Cal. Code Regs. Tit. 8, § 9785.4
2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).
3. Amendment of NOTE filed 9-21-2015; operative 10-1-2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 39).
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4061.5, 4600, 4603.2, 4636, 4604.5, 4660, 4662, 4663 and 4664, Labor Code.
2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).
3. Amendment of Note filed 9-21-2015; operative 10/1/2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 39).