A19-J.6 DMS Report Template.xlsx

XLSX spreadsheet 21 KB Posted Nov 24, 2025

Attached to: Directed Medical Services for the Department of Labor, Office of Workers' Compensation Programs (OWCP), Division of Federal Employees Compensation (DFEC) program
Solicitation number: 1605C3-25-R-00007_Amendment0001
Issued by: Department of Labor Office of the Assistant Secretary for Administration and Management

About this file

Written by GovTribe AI · Nov 24, 2025

This file is a DMS (Directed Medical Services) report template for tracking medical examination and reporting details for workers' compensation claims. The template captures comprehensive data points including referral information, claimant details, appointment specifics, and various performance metrics related to medical service delivery. Key tracked elements include referral numbers, claim numbers, claimant names, physician specialties (orthopedic surgery, pulmonary medicine, otolaryngology, neurology, psychiatry), service types (SECOP, IME, impairment rating, file reviews), and multiple timing metrics such as days between referral, appointment, and report delivery. The template is designed to monitor and record performance indicators for medical examinations and reports, with columns tracking urban/rural locations, appointment distances, report delivery timelines, and reasons for potential rescheduling, providing a structured approach to managing medical service referrals for workers' compensation claims.

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Sample report

Referral #	Claim #	Claimant Name	Date of Referral	Date of Program approval for IME	Specialty ( orthopedic surgery, pulmonary medicine, otolaryngology, neurology, and psychiatry)	Type of Service (SECOP, IME, Impairment rating, File Review Surgical, File Review Impairment, File Review Other)	Physicians Name	City and State of Claimant	Zip Code of Claimant	Urban or Rural	Appointment Distance from Claimant	Notice of Appointment Date Sent to Claimant	Date of Appointment	Date Medical Report Delievered	Supplemental Report Requet Date	Date of Supplemental Report Delivered	Clarification Request Date	Date Clarification Report Delievered	Date Reschedule Requested	Reason for Reschedule (Doctors office, Claimant Request and Claimant no show)	Date of Rescheduled appointment	# of Days to Deliver Conforming SECOP Report	# of Days to Deliver Conforming IME Report	# of Days to Deliver Conforming Impairment Rating Report	# of Days to Deliver File Review Surgical Report	# of Days to Deliver File Review Impairment Report	# of Days to Deliver File Review Other Report	# of Days to Supplemental Report	# of Days to Clarification Report	# of Days from Referral to Appointment -SECOP	# of Days from Referral to Program Approval Request	# of Days from Program Approval to Appointment (IMEs)
1	654321	John Doe	3/15/25	3/12/25	Orthopedic Surgery	SECOP	Bill James	Omaha, NE	68123	Urban or Rural	45	3/25/25	4/15/25	4/21/25	12/15/25	1/30/26	1/30/25	2/25/25				6						46	26	31	3	34
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Instructions

COLUMN	HEADER	MEANING
A	Referral No.	Identifies the numerical number assigned for the referral.
B	Claim #	Identifies the claim number
C	Claimant Name	Identifies the First and Last name of the claimant
D	Date of referral	Identifies the actual date referral was received.
E	Date of Program approval for IME	Identifies the actual date the Program approved the Physician for IME exams only
F	Specialty ( orthopedic surgery, pulmonary medicine, otolaryngology, neurology, and psychiatry)	Identifies the physician specialty for the examination or file review
G	Type of Service (SECOP, IME, Impairment rating, File Review Surgical, File Review Impairment, File Review Other)	Identifies the type of service associated with the referral
H	Physicians Name	Identifies the name of the physician assigned to the case
I	City and State of Claimant	Identifies the state the claimant resides in.
J	Zip Code of Claimant	Identifies the zip code the claimant resides in
K	Urban or Rural	Identifies if the claimant is in a urban or rural area
L	Appointment Distance from Claimant	Identifies the distance the appointment is from the claimants residence
M	Notice of Appointment Date Sent to Claimant	Identifies the date the "Notice of Exam" was received.
N	Date of Appointment	Identifies the date claimant received Medical Examination.
O	Date Medical Report Delivered	Identifies the date the medical report was delivered
P	Supplemental Report Request Date	Identifies the date the supplemental report was requested
Q	Date of Supplemental Report Delivered	Identifies the date the supplemental report was delivered
R	Clarification Request Date	Identifies the date the clarification of the report was requested
S	Date Clarification Report Delivered	Identifies the date the clarifying report was delivered
T	Date Reschedule Requested	Identifies the date the rescheduling of the examination was requested
U	Reason for Reschedule (Doctors office, Claimant Request and Claimant no show)	Identifies the reason the examination needs to be rescheduled
V	Date of Rescheduled appointment	Identifies the date of the examination for the rescheduled appointment
W	# of Days to Deliver Conforming SECOP Report	Identifies the number of days from SECOP appointment to medical report delivery
X	# of Days to Deliver Conforming IME Report	Identifies the number of days from IME appointment to medical report delivery
Y	# of Days to Deliver Conforming Impairment Rating Report	Identifies the number of days from IME appointment to medical report delivery
Z	# of Days to Deliver Conforming File Review Surgical Report	Identifies the number of days from the date of referral to medical report delivery
AA	# of Days to Deliver Conforming File Review Impairment Report	Identifies the number of days from the date of referral to medical report delivery
AB	# of Days to Deliver File Review Other Report	Identifies the number of days from the date of referral to medical report delivery
AC	# of Days to Supplemental Report	Identifies the number of days from the date of the supplemental request to supplemental report delivery
AD	# of Days to Clarification Report	Identifies the number of days from the date of the clarification request to clarification report delivery
AE	# of Days from Referral to Appointment -SECOP	Identifies the number of days from the date of referral to the date of the appointment

File details come from the government source that posted it. Updated Nov 24, 2025.