C T onable o North American Risk Services, Inc. t en tsf Workers’ Compensation CLAIMS FILE DOCUMENTATION EXPECTATIONS NARS W 14-DAYS a MEDICAL PROVIDER/MEDICAL MANAGEMENT y U W Expectation: Due by the 14th day from the date reported. Copy and paste the template into the file and fill it in. If nit MC C medical information is unavailable, document the medical is unknown but update the file as soon as it is received. r anagedo f Template eror s • Date of Visit: f orW • Physician’s Name: SC C • Physician’s Telephone Number: pecialistsr • Clinical Diagnosis: edo • ICD9/ ICD 10 Code: • Treatment Plan: • Referrals: P r • Work Status: acticB • Restrictions (if any): esest • Next Appointment Date U Example Checklistnit M Date of visit: 5/1/21 anag er Physician’s Name: Dr. John Smith Hospital: Mercy Hospital Telephone Number: 309-221-2200 ChecklistSW Clinical Diagnosis: Low Back Strain pecialist C Claims ICD 9/ICD 10 Code: Treatment Plan: Recommending physical therapy 3 x week for 4 weeks, NSAIDS, MRI of the lumbar spine, FU in 6 weeks (include date). Work Status: Completely off work, first full day off 4/20/21 14 DExpecta Restrictions: No work F Next Appt. Date: 5/15/21 a tionsile y *ATTACH MEDICAL RECORD TO NOTE. s Expecta F tionsile R e f erD encisability e G uide CaN t o egt orieses and 14 15