UCDHS Compliance Office
Documentation Notice
Date Issued: 3/29/06
Workers’ Compensation Services
Guidelines for Reporting Duties of the Primary Treating Physician
Definition:
A. The “primary treating physician” is the physician who is primarily responsible for
managing the care of an employee, and who has examined the employee at least once for
the purpose of rendering or prescribing treatment and has monitored the effect of the
treatment thereafter.
Reporting Requirements:
B.
The primary treating physician is responsible for submitting reports to the claims
administrator as required by the California Code of Regulations, Title 8, §9785. Sending
only one copy of the required report to the claims administrator satisfies the reporting
requirement. Reports may be transmitted to the claims administrator by mail or FAX or
by any other means satisfactory to the claims administrator, including electronic
transmission.
1. Doctor’s First Report of Occupational Injury or Illness
• Submit this report within 5 working days following the initial examination
• Submit this report using Form DLSR 5021
• Emergency and urgent care physicians are also required to submit a Form
DSLR 5021 following the initial visit
• On line 24 of the form, all of the following information should be included, as
appropriate:
o list methods, frequency and duration of planned treatment(s),
o specify planned consultation or referrals, surgery or hospitalization,
and
o specify the type, frequency and duration of planned physical
medicine services (e.g., physical therapy, manipulations,
acupuncture)
• Each new primary treating physician is required to submit a Form DLSR 5021
following his/her initial examination of the employee
2. Primary Treating Physician’s Progress Report
• Submit this report within 20 days when any one or more of the following
occurs:
o The employee’s condition undergoes a previously unexpected
significant change;
o There is any significant change in the treatment plan reported,
including but not limited to:
an extension of duration or frequency of treatment
a new need for hospitalization or surgery
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UCDHS Compliance Office
Documentation Notice
Date Issued: 3/29/06
Workers’ Compensation Services
Guidelines for Reporting Duties of the Primary Treating Physician
•
•
a new need for referral to or consultation by another physician
a change in methods of treatment or in required physical
medicine services, or
a need for rental or purchase of durable medical equipment or
orthotic devices;
o The employee’s condition permits return to modified or regular work;
o The employee’s condition requires him or her to leave work, or
requires changes in work restrictions or modifications;
o The employee is released from care;
o The primary treating physician concludes that the employee’s
permanent disability precludes, or is likely to preclude the employee
from engaging in the employee’s usual occupation or the occupation
in which the employee was engaged at the time of the injury;
Submit this report within forty-five days from the last report if no event
described above has occurred. If examination has occurred, submit the report
within 20 days of the examination.
Submit this report using Form PR-2 or in the form of a narrative report. If a
narrative report is used, it must:
o be entitled “Primary Treating Physician’s Progress Report” in boldfaced type;
o indicate clearly the reason the report is being submitted;
o contain the same information using the same subject headings in the
same order as Form PR-2; and
o as in Form PR-2, contain the following declaration: “I declare under
penalty of perjury that this report is true and correct to the best of my
knowledge that I have not violated Labor Code §139.3”.
3. Requests for appropriate additional information by the claims administrator
• A claims administrator may request additional information necessary to
administer the claim
• Submit response to this request by using Form PR-2, or in a narrative report
letter format. A letter format response must also include the same declaration
under penalty of perjury as found in Form PR-2
4. Primary Treating Physician’s Permanent and Stationary Report
• Submit report when the employee’s condition is determined to be permanent
and stationary
• Submit report within 20 days from the date of examination
• Report must include:
o any findings concerning the existence and extent of permanent
impairment
o limitations, and
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UCDHS Compliance Office
Documentation Notice
Date Issued: 3/29/06
Workers’ Compensation Services
Guidelines for Reporting Duties of the Primary Treating Physician
•
o any need for continuing and/or future medical care resulting form the
injury.
Submit the report using Form PR-4
C. It is the responsibility of the primary treating physician to obtain all reports from other
health care providers to whom the employee is referred.
• Within 20 days of receipt of each report, he/she must incorporate, or comment
upon, the findings and opinions of the other physicians, in his/her report and
submit all the reports to the claims administrator.
D. By mutual agreement between the physician and the claims administrator, the physician
may make reports in any manner and form.
Resources:
California Code of Regulations, Title 8, Section 9785
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