The WC196 Rehabilitation Communication form was created by the Division of Workers’ Compensation to report a physical or occupational therapist’s subjective and objective findings to the referring physician.

The subjective portion of the form records the patient’s self-report about improvement and the ability to perform job duties. The form documents the patient’s compliance with rehabilitation visits and the therapist’s assessment of the patient’s effort during rehabilitation.

The objective findings include range of motion measurements and manual muscle testing. The report records the name and results of the functional outcomes tool utilized. The specific, functional and measurable goals agreed on by the patient are recorded along with the time frame for completion. In subsequent visits, the percentage of achievement is documented. The assessment and plan are included on the form along with the signature of the therapist and the date of the visit.

• A physical or occupational therapist may utilize a Rehabilitation Communication Form (WC196) no more than every two weeks for the first six weeks, and once every four weeks thereafter.
• The WC196 form shall not be used for an evaluation, reevaluation or reassessment.
• The WC196 form must be completed and include which validated functional tool was used for assessing the patient.
• Once completed, the form shall be sent to the referring physician before or at the patient’s follow up appointment with the physician to aid in communication.
  

Billing code DOWC Z0817 $15.61

If you have any questions or need additional information, please contact Pinnacol’s provider medical billing auditors at 303.361.4940 or billingsuccess@pinnacol.com.

WC196 Rehabilitation Communication form

DOWC Rules of Procedure, Rule 18-4(H)(5)(b)