PRACTITIONER'S REPORT (FORM M-1)
GUIDELINES FOR COMPLETING THE M1 FORM
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ESTIMATED LENGTH OF TREATMENT: describe in
days, weeks, or months
TREATMENT PLAN: INCLUDE items like REST,
MEDICATION, EXERCISE, or other forms of treatment
MEDICAL REFERRALS: INCLUDE items like THERAPY,
SURGEON, CHIROPRACTIC, etc.
MODIFIED WORK: INDICATE RIGHT or LEFT as
appropriate; FREQUENCY (Never, Occasional <33% use) and DURATION of
activities allowed
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DUTIES OF HEALTH CARE PROVIDERS
Pursuant to
39-A M.R.S.A.
§208(2), duties of
health care providers are as follows:
* Except for claims for medical benefits only, within 5
business days from the completion of a medical examination or within 5 business
days from the date notice of injury is given to the employer, whichever is
later, the health care provider treating the employee shall forward to the
employer and the employee a diagnostic medical report, on forms prescribed by
the board, for the injury for which compensation is being claimed. The report
must include the employee's work capacity, likely duration of incapacity,
return to work suitability and treatment required. The board may assess
penalties up to $500 per violation on health care providers who fail to comply
with the 5-day requirement of this subsection.
* If ongoing medical treatment is being provided, every 30
days the employee's health care provider shall forward to the employer and the
employee a diagnostic medical report on forms prescribed by the board. An
employer may request, at any time, medical information concerning the condition
of the employee for which compensation is sought. The health care provider
shall respond within 10 business days from receipt of the request.
* A health care provider shall submit to the employer and the
employee a final report of treatment within 5 working days of the termination
of treatment, except that only an initial report must be submitted if the
provider treated the employee on a single occasion.
* Upon the request of the employee and in the event that an
employee changes or is referred to a different health care provider or
facility, any health care provider or facility having medical records regarding
the employee, including x rays, shall forward all medical records relating to
an injury or disease for which compensation is claimed to the next health care
provider. When an employee is scheduled to be treated by a different health
care provider or in a different facility, the employee shall request to have
the records transferred.
* A health care provider may not charge the insurer or
self-insurer an amount in excess of the fees prescribed in §209-A for the
submission of reports prescribed by this section and for the submission of any
additional records.
* An insurer or self-insurer may withhold payment of fees for
the submission of any required reports of treatment to any provider who fails
to submit the reports on the forms prescribed by the board and within the time
limits provided. The insurer or self-insurer is not required to file a notice
of controversy under these circumstances, but must notify the provider that
payment is being withheld due to the failure to use prescribed forms or to
submit the reports in a timely fashion. In the case of dispute, any interested
party may petition the board to resolve the dispute.
Other reminders:
* Except for the header information, the remainder of the M-1
form must be completed by the health care provider. This information is vital
to the administration of the claim and the employee's return to work.
* The M-1 form is not submitted to the board.
* Pursuant to Board Rules Chapter 5, a health care provider
may charge a fee for completing the initial M-1.
* The attachment of narratives is optional; however, an
employer/insurer may request, at any time (for a fee), medical information
concerning the condition of the employee for which compensation is sought. The
health care provider shall respond within 10 business days from receipt of the
request. Pursuant to
39-A M.R.S.A.
§208(1) a medical
release is not necessary if the information pertains to an injury claimed to be
compensable under the Act (whether or not the claim is
controverted/denied).
