Return To Work-Medical Verification Form printable pdf download

RETURN TO WORK / MEDICAL VERIFICATION FORM

MPLOYEE TO

OMPLETE

Employee Name: ___________________________________________________

Date of Birth________________

Home Address: __________________________________________________________________________________

City: ________________________________ State:______________ Zip: _______________

Home Phone No.:______________________

Job Title: ________________________________________ Department: _________________________________

Supervisor: _________________________________________

Employees who are absent from work for more than five consecutive days, are involved in a work-

related accident or incident, or who are requested must submit this Return to Work / Medical

Verification form to their supervisor before returning to work. Further, the employee must execute

the Release of Information on Page 2.

If illness or injury was treated by more than one provider A RETURN TO WORK FORM MUST

BE SUBMITTED FOR EACH TREATMENT PROVIDER prior to returning to work.

PHYSICIAN / PROVIDER CERTIFICATION

This is to certify that the patient named above has been under my professional care. I prescribed his/her

absence from work starting on _______________________ through and including __________________.

Patient may return to work on ______________________________ with no restrictions.

Patient may return to work on ____________________________ with restrictions explained more fully

on the Page 2.

Patient will be reevaluated on_________________________ and should remain off work until released.

I hereby certify that the above information is true and correct and that it is my responsibility to give objective

medical information. Concord University will take the suggestions that medical providers make into consideration,

but it is the employer's decision as to whether the accommodation can be met in a reasonable fashion.

Print Treatment Provider’s Name/Certification (D.O. M.D., etc.):

Address:

City/State/Zip:

Phone Number:

Fax Number:

___________________________________________________

Treatment Provider’s Signature

Date

Concord University PO Box 1000 Athens, WV 24712

Fax to Human Resources: (304) 384-5178

January 12, 2015

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Return To Work-Medical Verification Form