LS-204 proposed Attending Physician's Supplementary Report

Attending Physician's Supplementary Report

U.S. Department of Labor

(Longshore and Harbor Workers' Compensation Act, as extended)

Employment Standards Asministration
Office of Workers' Compensation Programs

www.dol.gov/esa/owcp/dlhwc/index.htm
OBM No.
1215-0160
INSTRUCTIONS: Use this form to make progress reports and to make a final report when the patient is discharged.
Progress reports should be submitted about every thirty days, the original to the District Director (See Item 19 on page
2) and one copy to the insurance carrier or self-insured employer. Please answer all questions fully. If a question is not
FOR OFFICE USE
applicable, enter "NA", The exact point of amputation or others permananent partial impairment must be known to
OWCP No.
determine compensation the injured is entitled to receive. If preferred, the physician may submit a narrative report
covering all information requested on this form. Use "Remarks" on page 2 of form if more space is needed for any
Carrier's No.
answer.
1. Type of report (Mark X one)
[ ] Progress

2. Date of Injury (mm/dd/yyyy)
[ ] Final

3. Name of Injured employee

4. Employee's home address

5. Name of employer

6. Name of insurance carrier

7a. Have you filed a previous report giving history?
[ ] Yes - Skip to item 8

[ ] No - Answer 7b and 7c

7b. State how many injury occurred and give source of information. (If 7c. Was employee previously under the care of another physician for this
claim is for occupational disease, include occuparional history and date injury?
o onse of mated symptoms)
[ ] No
[ ] Yes - Give physician's name and address
and reason for transfer

8. Is there any history or evidence of pre-existing injury, disease or physicl impairment?

9a. Present condition (include diagnosis, subjective complaints,
objective findings, and any changes of condition since last report.)

9b. If employee was hospitalized since last report, indicate and give name
and address of hospital.

10a. Describe treatment provided

10b. Date of first treatment

10c. Date of most recent treatment

10d. Has treatment been terminated?
[ ] No

10e. Are you continuing treatment?

[ ] Yes - Indicate reason

10f. If treatment is continuing estimate
probable duration

This form is used to request medical information which will be used to determine an injured worker's entitlement to compensation and medical
benefits. While you are not required to respond on this form, your cooperation is needed to insure that the injured worker's compensation case is
properly processed by the U.S. Department of Labor.
Form LS-204
Rev. April 2009

11. Will the injury result in permanent restriction, total or partial loss of function of a part or member, or permanent disfigurement of the head, face, or
neck, or some other part of the body which will handicap the employee in securing or maintaining employment?

12. Is employee working?
[ ] Yes

[ ] No

13. When do you estimate employee can - (mm/dd/yyyy)
a. Resume limited work of any kind

b. Resume regular work

Date

Date

14. If employee is unable to do his/her regular work, but can do lilmited work, specify work limitations due to this injury.

15. In your opinion, was the occurrence described above (or in the previous report which gave this information) the competent producing cause of the
injury and disability?
[ ] Yes

[ ] No

16. Is rehabilitation treatment or service or evaluation recommended? [ 17. If rehabilitation treatment or service or evaluation is recommended, has
] Yes - Explain [ ] No - Expalin
referral been made? [ ] Yes - To Whom [ ] No - Explain

18. Remarks

19. Send the original of your report to:
Office of the District of Columbia
U.S. Department of Labor
Office of Workers' Compensation Programs

20. Name of attending physician (Type or print)

21. Signature of physician

22. Address

23. Telephone No. (Area Code)

24. Date of report

PRIVACY ACT OF 1974 NOTICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers'
Compensation Act, (LHWCA) as amended and extended (33 U.S.C. 901 et seq.) is administered by the Office of Workers' Compensation Programs of
the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the
Office has will be used to determine eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to the employer
which employed the claimant at the time of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (4)
Information may be given to physicians and other medical service providers for use in providing treatment or medical/vocational rehabilitation, making
evaluations and for other purposes relating to the medical management of the claim. (5) Information may be given to the Department of Labor's Office
of Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render decisions with respect to the
claim or other matter arising in connection with the claim. (6) Information may be given to Federal, state and local agencies for law enforcement
purposes, to obtain information relevant to a decision under the LHWCA to determine whether benefits are being and have been paid properly, and
where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by law. (7) Failure to disclose all requested
information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Public Burden Statement
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended.
The authority for requesting the following information is 33 U.S.C. 907 (b). Use of this form is optional, however furnishing the information is required
in order to obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is
not required to respond to, a collection of information unless is displays a valid OMB control number. The valid OMB control number for this
information collection is 1215-0160. The time required to complete this informatin collection is estimated to average 30 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any aspect of this collection of information, including
suggestions for reducing this burden, to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C-4315, 200
Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE