Compromise And Release
Compromise and ReleaseOCR form sample packetThis packet contains instructions on how to fill in Optical Character Recognition (OCR)forms, examples of forms and is in the order in which forms / documents should be filedwith the district office.Use the table below to help identify the forms that you need to complete when filing acompromise and release. The table also shows the order in which the forms should beassembled. To help you find the correct document separator sheet, the product deliveryunit, document type and document title are in brackets.In this packet, you will see examples as filed by the applicant attorney for injuredworker.Name of form1 Document cover sheetDocument separator sheet2 [ADJ-LEGAL DOCS-COMPROMISE AND RELEASE]Compromise and release form3- may include addendumDocument separator sheet for QME report4 [ADJ-MEDICAL DOCS-QME REPORT]5 QME reportDocument separator sheet for proof of service6 [ADJ-LEGAL DOCS-PROOF OF SERVICE]7 Proof of serviceDivision of Workers’ Compensationwww.dwc.ca.gov(800) 736-7401
STATE OF CALIFORNIADWC DISTRICT OFFICEThis packet is an example ofhow to fill in forms and theorder in which they should be filedwith the district office.Is this a new case?YesThis example shows documentssubmitted by a representedinjured worker.DOCUMENT COVER SHEETNoCompanion Cases Exist More than 15 Companion Cases09/10/2008YesWalkthroughENTER DATE YOU FILL IN DOCUMENT COVER SHEET. SOCIAL SECURITYNUMBER IS NOTREQUIRED.SSN:Date:(MM/DD/YYYY)NoSpecific InjuryADJ123456Case Number 1Cumulative Injury(End Date: MM/DD/YYYY)(Start Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)NO OTHER INFORMATIONIS NEEDED WHENCORRECT CASE NUMBERIS LISTED.Body Part 1:Body Part 2:Body Part 3:Body Part 4:Other Body Parts:Please check unit to be filed on ( check only one box ) ADJDEUSIFUEFINTRSUCompanion CasesNO OTHERINFORMATION ISADJ67890NEEDED WHENCase Number 2 CORRECT CASENUMBER IS LISTED.Specific InjuryCumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 7/2010 - Page 1 of 8Example
Specific InjuryCase Number 3Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 4Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:DO NOT PRINT ORSUBMIT BLANKPAGES.Other Body Parts:Specific InjuryCase Number 5Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 11/2008- Page 2 of 8Example
District office codes for place of eAnaheimSanta AnaBakersfieldEurekaFresnoGoletaLos AngelesLong BeachMarina del linasSan BernardinoSan DiegoSan FranciscoSan JoseSan Luis ObispoSanta RosaStocktonVan NuysUse this document to complete forms, but do not file this document with your forms.DO NOT PRINT ORSUBMIT THIS PAGE.DWC-CA form 10232.1 Rev. 7/2010 - Page 7 of 8Example
Body Part Code ListThe body part codes listed below are used to complete forms that require the listing ofthe part of the body that is in issue. Please do not file this document with your 20430440450498Head - not specifiedBrainEar - not specifiedEar - externalEar - internal including hearingEye - including optic nerves and visionFace - not specifiedJaw - including chin and mandibleMouth - including lips, tongue, throat and tasteTeethNose - including nasal passages, sinus and smellFace - multiple parts any combination ofabove partsFace - forehead, cheeks, eyelidsScalpSkullHead - multiple injury any combination ofabove partsNeckUpper extremities - not specifiedArm - above wrist not specifiedArm - upper arm humerusArm - elbow head of radiusArm -forearm radius and ulnaArm - multiple parts any combination ofabove partsArm - not specifiedWristHand - not wrist or fingersFingersUpper extremities - multiple parts any combinationof above partsTrunk - not specifiedAbdomen - including internal organs and groinHerniaBack - including back muscles, spine and spinal cordChest - including ribs, breast bone and internalorgans of the chestHips - including pelvis, pelvic organs, tailbone,coccyx and buttocksShoulders - scapula and clavicleTrunk - use for side; multiple parts any combinationof above 810820830840841842850860870880999Lower extremities - not specifiedLegs - above ankles, not specifiedThigh femurKnee PatellaLower leg tibia and fibulaLeg - multiple parts any combination ofabove partsLeg - not specifiedAnkle malleolusFoot not ankle or toeToesLower extremities - multiple parts anycombination of above partsMultiple parts more than five major partsuse only in fifth position of listing of body partsBody system - not specificCirculatory system - heart -other than heartattack, blood, arteries,veins, etc.Circulatory system - Heart attackDigestive system - stomachExcretory system - kidneys, bladder, intestines,etc.Musculo-skeletal system - bones, joints, tendons,muscles, etc.Nervous system - not specifiedNervous system - stressNervous system - Psychiatric/psychRespiratory system - lungs, trachea, etc.Skin dermatitis, etc.Reproductive systemsOther body systemsUnclassified - insufficient information toidentify body partsDO NOT PRINT ORSUBMIT THIS PAGE.Use this document to complete forms, but do not file this document with your forms.DWC-CA form 10232.1 Rev. 11/2008 - Page 8 of 8Example
DOCUMENT SEPARATOR SHEETProduct Delivery UnitADJDocument TypeLEGAL DOCSDocument TitleCOMPROMISE AND RELEASEENTER DATE YOU FILL IN DOCUMENT SEPARATOR SHEET.Document Date09/10/2008MM/DD/YYYYIF YOU ARE A CLAIMS ADMINISTRATOR,HEARING REPRESENTATIVE OR LAW FIRMUSE YOUR UNIFORM ASSIGNED NAME.AuthorUNIFORM ASSIGNED NAMEOffice Use OnlyReceived DateDWC-CA form 10232.2 Rev. 11/2008 Page 1MM/DD/YYYYExampl
STATE OF CALIFORNIADIVISION OF WORKERS' COMPENSATIONWORKERS' COMPENSATION APPEALS BOARDCOMPROMISE AND RELEASEENTER ALL EAMS CASENUMBERS THAT APPLIES.ADJ123456Case Number 1Case Number 4ADJ45678Case Number 2Case Number 5Case Number 3SSN (Numbers Only)Venue Choice is based upon: (Completion of this section is required)CHECK THE BOX THAT APPLIES.County of residence of employee (Labor Code section 5501.5(a)(1) or (d).)County where injury occurred (Labor Code section 5501.5(a)(2) or (d).) County of principal place of business of employee’s attorney (Labor Code section 5501.5(a)(3) or (d).)OAKPUT 3 LETTER CODE OF DISTRICT OFFICE OFWHERE HEARING WILL BE HELD.Select 3 Letter Office Code For Place/Venue of Hearing (Fromm Document Cover Sheet)Employee(Completion(Completion of this section is required)JANEFirst NameMIDOELast Name345 MAIN STAddress/PO Box (Please leave blank spaces between numbers, names or words)OAKLANDCAStateCity94622Zip CodeEmployer Information (Completion of this section is required) InsuredSelf-InsuredLegally UninsuredUninsuredPREMIUM CRACKERSEmployer Name (Please leave blank spaces between numbers, names or words)660 E 7TH STEmployer Street Address/PO Box (Please leave blank spaces between numbers, names or words)OAKLANDCityDWC-CA form 10214 (c) (Rev. 11/2008) (Page 1 of 9)ExampleCAState95409Zip Code
Applicant's Attorney or Authorized Representative: Law Firm/AttorneyNon Attorney RepresentativeJANEFirst NameSMITHLast Name568901Law Firm NumberPUT UAN OF LAW FIRM.ABLE ATTORNEY ALAMEDALaw Firm NameENTER THE ADDRESS THATIS IN EAMS DATABASE.12345 FIRST STAddress/PO Box (Please leave blank spaces between numbers, names or words)CAALAMEDAStateCity94501Zip CodeDefendant's Attorney or Authorized Representative: Law Firm/AttorneyNon Attorney RepresentativeJIMFirst NameJONESLast Name577889Law Firm NumberPUT UAN OF LAW FIRM.RESPONSIBLE ATTORNEY SAN LEANDROLaw Firm NameENTER THE ADDRESS THATIS IN EAMS DATABASE.45890 EIGHT STAddress/PO Box (Please leave blank spaces between numbers, names or words)SAN LEANDROCityCAState97852Zip CodeInsurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator)EXPRESS INSURANCE COMPANYInsurance Carrier Name (Please leave blank spaces between numbers, names or words)PO BOX 458901Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words)SACRAMENTOCityDWC-CA form 10214 (c) (Rev. 11/2008) (Page 2 of 9)ExamplCAState95800Zip Code
Claims Administrator Information (if known and if applicable)PUT UAN OF CLAIMS ADMINISTRATOR.SPRING CLAIMS MODESTOName (Please leave blank spaces between numbers, names or words)PO BOX 123590Street Address/PO Box (Please leave blank spaces between numbers, names or words)CAMODESTO93489StateCityZip CodeIT IS CLAIMED THAT:1. The injured employee, born08/08/1945(DATE OF BIRTH: MM/DD/YYYY), alleges that while employed as a(n), sustained injurySTOCKER(OCCUPATION AT THE TIME OF INJURY)arising out of and in the course of employment at the locations and during the dates listed below:(State with specificity the date(s) of injury(ies) and what part(s) of body, conditions or systems are being settled.) Specific InjuryADJ12345603/09/2002Case Number 1Body Part 1:Body Part 2:420 BACK(If Specific Injury, use the start date as the specific date of injury)500 LOWER EXTBody Part 3:Other Body Parts:Body Part 4:The injury occurred at(End Date: MM/DD/YYYY)(Start Date: MM/DD/YYYY)Cumulative Injury660 EAST 7TH STMAY ENTER "ON JOB SITE OR WORK PLACE" OR ADDRESS.(Street Address/PO Box - Please leave blank spaces between numbers, names or words)CA95409.,Zip CodeCityStateBody parts, conditions and systems may not be incorporated by reference to medical reports.OAKLANDDWC-CA form 10214 (c) (Rev. 11/2008) (Page 3 of 9)Exampl
Specific InjuryADJ45678Case Number 2 05/30/2003Cumulative Injury01/01/2005(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 2:420 BACKOther Body Parts:Body Part 4:The injury occurred atBody Part 3:500 LOWER EXT660 E 7TH ST(Street Address/PO Box - Please leave blank spaces between numbers, names or words)OAKLAND94501CA.,CityZip CodeStateBody parts, conditions and systems may not be incorporated by reference to medical reports.Specific InjuryCase Number 3(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 2:Body Part 4:Other Body Parts:The injury occurred at(End Date: MM/DD/YYYY)(Start Date: MM/DD/YYYY)Cumulative InjuryBody Part 3:(Street Address/PO Box - Please leave blank spaces between numbers, names or words),CityStateZip Code.Body parts, conditions and systems may not be incorporated by reference to medical reports.Specific InjuryCase Number 4(Start Date: MM/DD/YYYY)Cumulative Injury(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 2:Body Part 3:Body Part 4:Other Body Parts:The injury occurred at(Street Address/PO Box - Please leave blank spaces between numbers, names or words)City,StateZip Code.Body parts, conditions and systems may not be incorporated by reference to medical reports.DWC-CA form 10214 (c) (Rev. 11/2008) (Page 4 of 9)Example
Specific InjuryCumulative InjuryCase Number 5Body Part 1:Body Part 2:Body Part 4:Other Body Parts:The injury occurred at(End Date: MM/DD/YYYY)(Start Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 3:(Street Address/PO Box - Please leave blank spaces between numbers, names or words),CityStateZip Code.Body parts, conditions and systems may not be incorporated by reference to medical reports.2. Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensationadministrative law judge and payment in accordance with the provisions hereof, the employee releases and foreverdischarges the above-named employer(s) and insurance carrier(s) from all claims and causes of action, whether now knownor ascertained or which may hereafter arise or develop as a result of the above-referenced injury(ies), including any and allliability of the employer(s) and the insurance carrier(s) and each of them to the dependents, heirs, executors,representatives, administrators or assigns of the employee. Execution of this form has no effect on claims that are not withinthe scope of the workers' compensation law or claims that are not subject to the exclusivity provisions of the workers'compensation law, unless otherwise expressly stated.3. This agreement is limited to settlement of the body parts, conditions, or systems and for the dates of injury set forth inParagraph No. 1 and further explained in Paragraph No. 9 despite any language to the contrary elsewhere in this document orany addendum.4. Unless otherwise expressly stated, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'SDEPENDENTS TO DEATH BENEFITS RELATING TO THE INJURY OR INJURIES COVERED BY THIS COMPROMISEAGREEMENT. The parties have considered the release of these benefits in arriving at the sum in Paragraph 7. Any addendumduplicating this language pursuant to Sumner v WCAB (1983) 48 CCC 369 is unnecessary and shall not be attached.5. Unless otherwise expressly ordered by the Workers' Compensation Appeals Board or a workers' compensationadministrative law judge, approval of this agreement does not release any claim applicant may have for vocationalrehabilitation benefits or supplemental job displacement benefits.6. The parties represent that the following facts are true: (If facts are disputed, state what each party contends underParagraph No. 9.)ENTER DOLLAR AMOUNT WITHOUT COMMAS.EARNINGS AT TIME OF INJURY TEMPORARY DISABILITY INDEMNITY PAIDPeriod(s) PaidIF INFORMATION IS NOT KNOWN, LEAVE BLANK.DO NOT ENTER N/A, NONE, ETC.2,500.0002/01/2005Weekly Rate 1,450.00125.0001/30/2007(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)PERMANENT DISABILITY INDEMNITY PAIDPeriod(s) PaidWeekly Rate End date(Start Date: MM/DD/YYYY)TOTAL MEDICAL BILLS PAID 5,500.00(End Date: MM/DD/YYYY)Total Unpaid Medical Expense to be Paid By:Unless otherwise specified herein, the employer will pay no medical expenses incurred after approval of this agreement.DWC-CA form 10214 (c) (Rev. 11/2008) (Page 5 of 9)Example
7. The parties agree to settle the above claim(s) on account of the injury(ies) by the payment of the SUM OF 50,000.00Settlement AmountThe following amounts are to be deducted from the settlement amount: for permanent disability advances through for temporary disability indemnity overpayment, if any. payable to payable to payable to payable to 5,000.00requested as applicant's attorney's fee., after deducting the amounts set forth above and lessLEAVING A BALANCE OF 45,000.00further permanent disability advances made after the date set forth above. Interest under Labor Code section 5800 isincluded if the sums set forth herein are paid within 30 days after the date of approval of this agreement.8. Liens not mentioned in Paragraph No. 7 are to be disposed of as follows (Attach an addendum if necessary):NO LIENSDWC-CA form 10214 (c) (Rev. 11/2008) (Page 6 of 9)Exampl
partiesies wish to settle these matters to avoid the costs, hazards and delaysy of further litigation,gand agreegthat a9. The partipseriouseriousdisputedisppexistsg issuesy thosepp HEAPPLICANTAND DEFENDANTS OR THEIR REPRESENTATIVES ARE INCLUDED WITHIN THISSETTLEMENT.ETTLEMEApplicant DefendantYearningsYtemporary ry AOE/COEserious and willful misconductdiscrimination (Labor Code §132a)statute of limitationsYfuture medical treatmentotherpermanent disabilityself-procured medical treatment, except as provided in Paragraph 7vocational rehabilitation benefits/supplemental job displacement benefitsCOMMENTS:ENTER ADDITIONAL INFORMATIONOR CONDITION IN THIS AREA.Any accrued claims for Labor Code section 5814 penalties are included in this settlement unless expressly excluded.10. It is agreed by all parties hereto that the filing of this document is the filing of an application, and that the workers'compensation administrative law judge may in its discretion set the matter for hearing as a regular application, reserving to theparties the right to put in issue any of the facts admitted herein and that if hearing is held with this document used as anapplication, the defendants shall have available to them all defenses that were available as of the date of filing of thisdocument, and that the workers' compensation administrative law judge may thereafter either approve this Compromise andRelease or disapprove it and issue Findings and Award after hearing has been held and the matter regularly submitted fordecision.DWC-CA form 10214 (c) (Rev. 11/2008) (Page 7 of 9)Example
11. WARNING TO EMPLOYEE: SETTLEMENT OF YOUR WORKERS' COMPENSATION CLAIM BY COMPROMISE ANDRELEASE MAY AFFECT OTHER BENEFITS YOU ARE RECEIVING TO WHICH YOU BECOME ENTITLED TO RECEIVE INTHE FUTURE FROM SOURCES OTHER THAN WORKERS' COMPENSATION, INCLUDING BUT NOT LIMITED TOSOCIAL SECURITY, MEDICARE AND LONG-TERM DISABILITY BENEFITS.THE APPLICANT'S (EMPLOYEE'S)) SIGNATURE MUST BE ATTESTED TO BY TWO DISINTERESTED PERSONSOR ACKNOWLEDGED BEFORE A NOTARY PUBLICBy signing this agreement, applicant (employee) acknowledges that he/she has read and understands this agreement andhas had any questions he/she may have had about this agreement answered to his/her satisfaction.Witness the signature hereof this day of , atFILL IN DATE AND LOCATION.SIGN AND DATE THE FORM.WHEN DOCUMENT IS NOTNOTORIZED, TWO DISINTERESTEDWitness 1WITNESSES TO SIGN AND DATETHE FORM.(Date)Applicant (Employee)(Date)Witness 2(Date)Attorney for Applicant(Date)Interpreter(Date)Attorney for Defendant(Date)Attorney for Defendant(Date)Attorney for Defendant(Date)Attorney for Defendant(Date)DWC-CA form 10214 (c) (Rev.11/2008) (Page 8 of 9)Exampl
COMPLETE THISSECTION IF NOTORIZED.ACKNOWLEDGMENTState of CaliforniaCounty of )On before me,(insert name and title of the officer)personally appeared ,who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/aresubscribed to the within instrument and acknowledged to me that he/she/they executed the same inhis/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument theperson(s), or the entity upon behalf of which the person(s) acted, executed the instrument.I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoingparagraph is true and correct.WITNESS my hand and official seal.SignatureDWC-CA form 10214 (c) (Rev. 11/2008) (Page 9 of 9)(Seal)Exampl
DOCUMENT SEPARATOR SHEETProduct Delivery UnitADJDocument TypeMEDICAL DOCSDocument TitleQME REPORTSDocument DateAuthorENTER DATE OF THEDOCUMENT FOLLOWINGTHE SEPARATOR SHEET.07/10/2007MM/DD/YYYYJOHN PHYSICIAN MDExample:JOHN A SMITH MDJOHN A SMITH PTUse only capital letters and no specialcharacters e.g. / \ ' . " , : ; ( ) & !Office Use OnlyReceived DateDWC-CA form 10232.2 Rev. 11/2008 Page 1MM/DD/YYYYExampl
0P170-0700-52Board Eligible Orthopaedic SurgeonQualified Medical EvaluatorQUALIFIED MEDICAL EVALUATIONMay 18,2007RE:DATE OF EVALUATION:EMPLOYER:DATE OF INJURY:CLAIM NO.:FILE NO:May 18,2007January 1,200551012-035inutes were spent face to face with the patient in the evaluation process.FEE DISCLOSUREML 104-95: This is an Unrepresented Qualified Medical Evaluation with Extraordinary Circumstances as aresult of meeting the requirements of 4 complexity factors, which are listed below: 7 hour(s) of record review time 3 hour(s) of report preparation time 35 minutes of face to face time 10 1/2 total hours of combined time Four hours or more of any combination of 2 complexity factors (2 factors) Addressing issues of causation (1 factor) Addressing issues of apportionment when the physician addresses: (1 factor)3 injuries to the SAME body system or region–ExampleExample
Page 2PROOF OF SERVICE:All reports are accompanied by the HICFA form stapled to the first page of thereport, along with a proof of service.Thank you for the opportunity to evaluateon Friday, May 18, 2007 inThe history and physical examination is not intended to be construed as a general orcomplete medical evaluation. It is intended for medical legal purposes only andfocuses on those areas in question, No treatment relationship is established orimplied.This medical-legal evaluation is based only on the current information and recordssubmitted. It is solely the treating physician’s responsibility to determine the patient’sdifferential diagnoses and subsequent needs for medical treatment. This would beinclusive of all psychiatric conditions, vascular diseases, neuromuscular disorders,central nervous system disorders, auto-immune diseases, internal medicine disordersand all tumors, benign or malignant, even if they are undiagnosed or currently occult.It is noted seven inches of medical records were reviewed. It is also noted that theapplicant has had previous industrial trauma therefore complex acts of apportionment,this should be an ML 104.HISTORY OF INJURYis aforShe Indicates she began working for this organization in 1986 and continueswith her normal activities at the present time. The applicant is seen at this time inconjunction with a claim of cumulative trauma through January 1, 2005.describes no specific industrial injury occurring at that time. She describes noworsening symptomatology occurring in 2005. She indicates that her back pain was“the same that I had for years”. She further states “Over the years, it is worse andworse.” She indicates she has been taking Celebrex “for years”.Her past medical history is significant for a specific industrial trauma occurringMarch 9, 2002. At that time, she indicates that she was lifting file boxes when herback “snapped”. She indicates she was seen by her family physician and later wasreferred for an MRI scan which was positive for a disc herniation atShe had applied for workers’ compensation and was referred to Dr.aneurosurgeon. Surgery was performed by Dr.on June 3, 1992 for diagnosisExampleExample
Page 3of herniated intervertebral disc at L5-SI level. She underwent an L4-5 laminectomyand discectomy procedure. She did note initial improvement after that surgery. Shewas deemed permanent and stationary by Dr.as of April, 29, 1993 and wasawarded a 24% permanent disability in conjunction with her back injury. Theapplicant states that she began developing gradual increasing symptomatology andunderwent a repeat MRI scan and was recommended by Dr.to undergofurther surgery. On January 17, 2000, the applicant underwent a bilateral L4-5laminectomy, nerve root decompression and posterior interbody fusion. She indicatedthat she did improve although she continued to have back pain. She has continued totreat with Dr.who sees her at yearly intervals.She was deemed permanent and stationary in regard to her second operativeprocedure as of April 18, 2002. He was referred by the insurance carrier to Dr.a spine surgeon who examined her on December 30, 2003. At that time,she was in constant pain. She was noted to have right buttock numbness withnumbness into the right third and fourth toes. Dr.commended furtherrenonoperative management.states that she continues under the care of Dr.who sees her at yearly intervals.CURRENT COMPLAINTSThe applicant describes pain in her lower back which is almost constant. She statesthat she will have pain daily. She states that the use of nonsteroidal anti-inflammatorymedications ( Celebrex) diminished the discomfort. She further indicated sitting formore than fifteen to thirty minutes a day is painful; standing more than fifteen tothirty minutes is painful. She indicates that lying down diminishes her pain, causespain of the lower back at the lumbosacral junction. She states that the right side of thelower back is more symptomatic than the left side. She describes decreased sensationover the anterior aspect of the right thigh with prolonged sitting. She describessensation of “numbish” feeling in the third and fourth toes of the right foot.REVIEW OF MEDICAL RECORDSJanuary 22, 1993 Progress Report from M.D. Has an injury March9, 1992. Dr.notes “It is my opinion that is postoperativelaminectomy and discectomy. I believe her condition is improved “November 8, 1993 fromM.D. It is my impression thatis able to perform her job duties without limitations.ExampleExample
Page 4November 20, 1998 MRI scan of the lumbar spine. Interpreted by Gregory Henzie,M.D. Impressions surgical changes on the right at L4-5, disc desiccation at L3-4, discdesiccation at L2-3.February 3, 1999 signed byM.D. At the time of her appointment, thepatient complained of moderate severe lower back pain and right leg pain andnumbness. Dr.recommended authorization to proceed with a posteriorlumbar interbody fusion using threaded fusion cages.August 4, 1999 Progress Report fromThe patient states that she iscontinuing to have constant lower back pain of severe intensity which increases withactivity.suffering from degenerative disc disease at the L4-5 level.January 17, 2000 Operative Report signed byM.D. Procedurebilateral L4-5 laminectomy, facetectomy nerve root decompression with posteriorinterbody fusion. The patient is a 51-year-old female who underwent priorlaminectomy discectomy in 1992 with recurrent back pain.June 5, 2001M.D. diagnoses lumbar disc disease.Treating Physician’s Consultation Report signed by Dr.dated April 18,2002 notes date of injury March 9,1992.Depositiondated June 21, 2005. Question: Are your currentlyworking? Answer: Yes. Question: When were you hired atAnswer: November 18, 1986. Question: Did you file a claim of cumulativetrauma? Answer: Yes. Question: February 15, 2004?Answer: Yes, though I amthinking this is 2005. Question: How did you sustain injury? Answer: By liftingboxes. Question: Did you sustain an injury in 1992; is that what you are referring to?Answer: Yes. Question: Did you receive an Award of Permanent Disability for 24%?Answer: Yes. Question: How many surgeries have you had in your back? Answer:There was one in June of 1992, a second one in January of 2000. Question: So youwent back to work full time after the 2000 surgery? Have you lost any time from workdue to your complaints of pain to your back? Answer: No. Question: Do youunderstand this as to Republic Indemnity because of the stipulations the only rightsyou have are to continue medical care? Answer: I understand.December 30, 2003 Initial consultation performedM.D.aiscomplaining of lower back pain. Plain films todayExample
Page 5demonstrate ray cage PLIF in place, essentially a complete laminectomy of L4 andmuch of L5 has been performed. Assessment: 1) possible pseudoarthrosis L4-5; 2)possible symptomatic adjacent disc degeneration lumbar spine. Dr. Neubergerrecommended further nonoperative management.October 7, 2005 Examination performedThe patient presentstoday slating that she had another episode where she had what she felt waspalpitations and ended up in the emergency room. Assessment: 1) continuedintermittent palpitations; 2) hypertension; 3) history of ulcerative colitis; 4) history ofhyper cholesterolemia.; 5) mild diabetes mellitus; 6) chronic lower back pain; 7)exogenous obesity.January 10, 2000 X-rays lumbar spine interpreted byImpression: Osteoporosis and mild degenerative changes as above.M.D.June 9, 1996 Neurosurgical consultation performedM.D.Impression: Lumbar spinal stenosis L4-5 with right sided L4 compressive neuropathy.As a result of the lifting incident March 9, 1992,persistent painin the right lower extremity which is aggravated by walking and hyperextension of thelower back.July 19, 1993 Progress Reportnotesbecame permanent and stationary as of April 29, 1993.conditionDecember 3, 1993 Examination performedM.D. Requestedsurgery by Dr.is posterior lumbar interbody fusion using threaded fusioncages at L4-5.Operative Report dated June 3, 1992 signedOperation right L4-5laminectomy, discectomy with partial facetectomy, nerve root decompressionmicrosurgical technique. Postoperative diagnosis: 1) Herniated intervertebral disc L45.PHYSICAL EXAMINATIONPhysical examination reveals a well-developed, well-nourishedHeight is 5’9”, weight is 200 pounds. She ambulates with a normal gait pattern. Shesits comfortably during her interview. She is able to get up and unassisted.ExampleExample
RE:Page 6Mid thigh circumference is measured at 20” bilaterally. Thigh circumference ismeasured as 15” bilaterally.She has normal sensation to pinprick in both extremities.Straight leg raising is negative bilaterally. Straight leg raising does cause her referredlower back pain. Sciatic stresses was negative bilaterally. Extensor hallucis longusmotor strength is normal and symmetrical in both extremities.She has normalsensation of pinprick in both extremities. Deep tendon reflexes are intact in bothextremities.She is able to toe walk, heel walk and squat. She describes no p
Body Part Code List . The body part codes listed below are used to complete forms that require the listing of the part of the body that is in issue. Please do not file this document with your forms. 100 Head - not specified 110 Brain 120 Ear - not specified 121 Ear - external 124 Ear - internal including hearing
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Welcome to the 2021 Business Email Compromise Report. Business Email Compromise (BEC) attacks are one of the financially most damaging cyber crimes. They typically involve phishing emails and social engineering tactics to attack organizations and trick unsuspecting employees and executives into conducting tasks under the guise of legitimate .
offer in compromise. The bankruptcy pro-cess will resolve any tax liabilities and other financial debts. If you do not fall under this category, then the IRS will accept an OIC on three grounds. First, if you have genuine "doubt" regarding your tax liability, then you will need to complete Form 656-L , Offer in Compromise. Second .
The decision to reject an offer in compromise is not subject to review. Page 2 The Commissioner may adopt rules regarding the procedures to be followed for the submission and consideration of offers in compromise. What are the Types of OIC? There are three types of OIC. It is important to pick the type of offer that best matches
An offer in compromise (offer) is an agreement between you (the taxpayer) and the IRS that settles a tax debt for less than the full amount owed. The offer . unless your household meets the Low Income Certiication guidelines (See page 2 of Form 656, Offer in Compromise). COMPLETING THE APPLICATION PACKAGE Step 1 - Gather your information .
Information Statement for Business, Form 656, Offer in Compromise . 5 IRS contact information If you have questions regarding qualifications for an offer in compromise (offer), please call our toll-free number at 1-800-829-1040. You can get forms and publications by calling 1-800-TAX-FORM
Compromise of disputes9 and doubtful rights10 is sufficient consideration for agreements. The abandonment of groundless claim will not make a good consideration.11 The consideration in a compromise or abandonment of a disputed or doubtful claim is " the surrender not of a legal 6 R. Rajanna v. S.R. Venkataswamy, AIR 2014 All 235. 7 Callisher v.
Offer in Compromise Submitting an Offer in Compromise is the process in which a taxpayer may reduce their Internal Revenue Service or State tax debt by negotiating with the taxing agency to accept an . Manual gives the following guidelines: 1. "Where under the terms of employment, a taxpayer is required to contribute a
