(1) The date of the in-person examination or record review;
(2) The patient's complaint(s);
(3) A listing of all information received from the parties reviewed in preparation of the report or relied upon for the formulation of the physician's opinion;
(4) The patient's medical history relevant to the diagnostic services, diagnosis or medical treatment;
(5) Findings on record review or in-person examination;
(6) The IMR's diagnosis;
(7) The physician's opinion whether or not the proposed treatment or diagnostic services are appropriate and indicated. If the proposed treatment or diagnostic services are not appropriate or indicated, any alternative diagnosis or treatment recommendation consistent with the medical treatment utilization schedule shall be included;
(8) An analysis and determination whether the disputed health care service is consistent with the medical treatment utilization schedule established pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines. For injuries not covered by the medical treatment utilization schedule or by the ACOEM guidelines, an analysis and determination whether the treatment rendered is in accordance with other evidence-based medical treatment guidelines which are generally recognized by the national medical community and scientifically based; and
(9) The signature of the physician.
(b) The report shall be in writing and use layperson's terms to the maximum extent possible.
(c) An Independent Medical Reviewer shall serve with each report the following executed declaration made under penalty of perjury:
I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code section 139.3.
Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 139.3, 4616.4 and 5307.27, Labor Code.
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 A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.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 subsections (a) and (c), transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).