Kristen Hernandez

 
 State of California 
 Division of Worker's Compensation 
 PRIMARY TREATING PHYSICIAN'S PROGRESS REPORT (PR-2) 
 Check the boxes which indicate why you are submitting a report at this time. If he patient is "Permanent and Stationary" 
 (I.e., has reached maximum medical improvement), do not use this form. You may use DWC Forms PR-3 or PR-4. 
 Periodic Report (Required 45 days after last report) 
 Change in treatment plan 
 Release from care 
 Change in work status 
 Need for referral or consultation 
 Response to request for informaton 
 Change in patient's condition 
 Need for surgery or hospitalization 
 Request for authorization 
 Other: 
 PATIENT: 
 Last: 
 Corona 
 First: Araceli 
 Middle: 
 Address: 1450 MADRONER DR 
 City: Salinas 
 State: 
 CA 
 Zip: 73319 
 Date of Injury: 
 Sex: 
 female 
 DOB: 
 02-07-1991 
 Occupation: 
 SSN: 617xxxx 
 Phone: 831xxxx 
  
 EMPLOYER NAME: Healthcare Services Group 
 Subjective Complaints: Worker's Compensation (WC DOI 12/721 BACK) 
 Diagnoses: 
 ICD-10- 
 CM 
 1. Lumbar strain, subsequent encounter 
 $39.012 
 D 
 Treatment Plan: 
 TREATMENT PLAN: Light work starting 12/15/2021. Physical therapy. Return 12/23/2021. 
 Orders Placed This Encounter 
 Ambulatory referral to Physical Therapy 
 DATE OF SERVICE: 
 08-20-2016
 CHIEF COMPLAINT: 
 Chief Complaint 
 Patient presents with 
 Worker's Compensation 
 WC DOI 02-18-2015 BACK 
 
 GB IA Recv 2021122107346 
 Received 01-12-2015
