Physician'S Notice Of Release To Work

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PHYSICIAN’S NOTICE OF RELEASE TO WORK
Submit to insurer within three (3) days of release to work
with a copy to the employee and his or her attorney.
DWC/MAB File #
Insurer’s File #
Employee/Patient Information:
Employer Information:
Social Security #
FEIN #
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Phone
Date of Birth
Injury Date:
Insurance Carrier:
Adjusting Company:
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Phone
If the insurer is not known, contact the Division of Workers’ Compensation at (401) 462-8100.
Section 28-33-8(b) of the RI Workers’ Compensation Act provides for a $20.00 fee to be charged for the
timely filing of this form.
This medical report is rendered pursuant to Section 28-33-8 of the RI Workers’ Compensation Act.
This is to certify that the above named employee is able to return to work on
_
__
Regular duty, no restrictions
Modified duty, limitations as follow:
To (check one)
Indicate modified duty restrictions:
__
__
No operating heavy machinery or vehicles
Alternate standing/sitting
__
__
No repetitive climbing ladders or stairs
No work involving use of right/left ___________
__
__
May lift up to ________ pounds only
Sit down work only
__
__
No reaching above shoulders
Keep wound clean and dry
__
__
No repetitive twisting, bending, squatting
Other _________________________________
__
No repetitive stooping, kneeling
_____________________________________
__
The patient will require no further medical items or medical services associated with this claim.
This certification is based on the medical examination performed on
Physician’s signature
Date
Physician’s name
Treatment facility
Physician’s Assistant Signature
Supervising Physician’s Name
Physician’s Address
Form DWC-27/28 (7/09) RI Department of Labor & Training, Division of Workers’ Compensation

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