Work Release Form printable pdf download

WORK RELEASE FORM

An application for Economic Support benefits was submitted to the Georgia Crime Victims Compensation Program (CVCP) for

consideration. To help the CVCP make the best possible decision in determining eligibility, we would appreciate your

assistance by providing the below information. This form is only required if the victim was out of work more than one (1)

week. This form is only required if the victim was out of work more than one (1) week.

Patient/Victim

Name: _______________________________________

Last 4 of SSN: ___________________

Address: _____________________________________

DOB: _____/_____/_____

Date of Crime: _____/_____/_____

Claim Number: ___________________

1. Date(s) patient/victim was under your care.

From: ____/____/____

To: ____/____/____

2. Is patient/victim permanently disabled and unable to work?

Yes

(a) if No, dates patient/victim was unable to work due to injuries

From: ____/____/____

To: ____/____/____

sustained during victimization.

(b) Date patient/victim is/was released to return to work.

______/______/______

3. Please describe the patient’s/victim’s condition that made him/her unable to perform work-related activities:

_______________________________________________________________________________________________

____________________________________

Medical Provider (print name)

____________________________________

Patient/Victim Signature

Medical Provider Signature

Date: _________/_________/____________

Telephone No.: _______-_______-________

____________________________________

Composite State Board of

Medical Examiners License No.

PLEASE NOTE: TO BE VALID, this form must be faxed or mailed by the MEDICAL PROVIDER.

An Equal Opportunity Employer

Work Release Form