California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5 - Predesignation of Personal Physician; Request for Change of Physician; Reporting Duties of the Primary Treating Physician; Petition for Change of Primary Treating Physician › Section 9785.4 - Form PR-4 "Primary Treating Physician's Permanent and Stationary Report."

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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' Compensation
PRIMARY 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
(a) Apportionment of permanent disability
					 shall be based on causation.
(b)
					 Any physician who prepares a report addressing the issue of permanent
					 disability due to a claimed industrial injury shall in that report address the
					 issue of causation of the permanent disability.
(c) In order for a physician's report to be
					 considered complete on the issue of permanent disability, it must include an
					 apportionment determination. A physician shall make an apportionment
					 determination by finding what approximate percentage of the permanent
					 disability was caused by the direct result of injury arising out of and
					 occurring in the course of employment and what approximate percentage of the
					 permanent disability was caused by other factors both before and subsequent to
					 the industrial injury, including prior industrial injuries. If the physician is
					 unable to include an apportionment determination in his or her report, the
					 physician shall state the specific reasons why the physician could not make a
					 determination of the effect of that prior condition on the permanent disability
					 arising from the injury. The physician shall then consult with other physicians
					 or refer the employee to another physician from whom the employee is authorized
					 to seek treatment or evaluation in accordance with this division in order to
					 make the final determination.
(d)
					 An employee who claims an industrial injury shall, upon request, disclose all
					 previous permanent disabilities or physical impairments.
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
(a) The employer shall only be liable for the
					 percentage of permanent disability directly caused by the injury arising out of
					 and occurring in the course of employment.
(b) If the applicant has received a prior
					 award of permanent disability, it shall be conclusively presumed that the prior
					 permanent disability exists at the time of any subsequent industrial injury.
					 This presumption is a presumption affecting the burden of proof.
(c)
(1) The
					 accumulation of all permanent disability awards issued with respect to any one
					 region of the body in favor of one individual employee shall not exceed 100
					 percent over the employee's lifetime unless the employee's injury or illness is
					 conclusively presumed to be total in character pursuant to Section
					 4662. As used in this section, the
					 regions of the body are the following:
(A)
					 Hearing.
(B) Vision.
STATE OF CALIFORNIA
Division of Workers' Compensation
PRIMARY TREATING PHYSICIAN'S PERMANENT AND
						STATIONARY REPORT (PR-4)
(C)
					 Mental and behavioral disorders.
(D) The spine.
(E) The upper extremities, including the
					 shoulders.
(F) The lower
					 extremities, including the hip joints.
(G) The head, face, cardiovascular system,
					 respiratory system, and all other systems or regions of the body not listed in
					 subparagraphs (A) to (F), inclusive.