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Rehabilitation communication form (WC196)

The WC196 Rehabilitation Communication form was created by the Division of Workers’ Compensation to

November 30, 2019
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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 should not be used for an evaluation, reevaluation or reassessment.
  • The WC196 form must be completed and must include which approved 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.
  • The form should be sent with the bill or faxed to 303.361.5910 or 877.820.6134.

Billing code DOWC Z0817 - $15.30 for 2020

Reference: DOWC Rehabilitation Communication form - WC196

If you have any questions, Pinnacol’s provider medical billing auditors would be happy to assist you. Please call the Medical Payments Team and Payment Appeals Department at 303.361.4940 or email

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