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. 38, September 20, 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' CompensationPRIMARY 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.)

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.

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

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

1. New section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).
3. Amendment of NOTE filed 9-21-2015; operative 10-1-2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 39).

Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4061.5, 4600, 4603.2, 4636, 4604.5, 4660, 4662, 4663 and 4664, Labor Code.