Sample Workers Compensation Referral For Medical Treatment
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1SAMPLE
WORKERS’ COMPENSATION REFERRAL FOR MEDICAL TREATMENT FORM
SCHOOL DISTRICT OF HILLSBOROUGH COUNTY, FLORIDA
INSTRUCTIONS: When an employee needs medical treatment due to on-the-job (Workers Compensation) injury or illness,
the work location completes Section II of this form and sends it with the employee to the medical facility. The Employee is
required to go to only a Managed Care Arrangement approved medical care coordinator. AVOID HOSPITAL EMERGENCY
ROOMS UNLESS THERE IS A SERIOUS OR LIFE THREATENING INJURY. The medical facility completes Section III and
the employee returns the form to the work location. The work location completes Section IV and sends the form to the District
Workers’ Compensation Office, Safety Office, Route 1 in the next school mail. Make a copy for your records. FOR
QUESTIONS CONCERNING COMPENSABILITY CALL 872-5267.
Employee Authorization for Release of Medical Information: I, the undersigned, hereby authorize the medical provider
(physician, nurse, hospital) completing this form to provide the School District of Hillsborough county and/or their Workers’
Compensation representative, RSKCo with any and all related information which may be requested regarding my physical
condition and treatment rendered thereof, and if necessary, to allow them or allow a physician appointed by them to examine any x-
ray pictures taken of me or records regarding my medical history, physical condition or treatment provided to me. A photo static
copy of this authorization is to be given the same force and effect as the original.
Employee Signature
S.S. #
/
/
Date
/
/
EMPLOYEE’S NAME
SCHOOL OR DEPT.
NAME OF APPROVED MEDICAL FACILITY WHERE EMPLOYEE IS SENT
WHAT HAPPENED?
PART(S) OF BODY AFFECTED:
THE FIRST VISIT TO YOUR MEDICAL FACILITY WILL BE COVERED BY WORKERS’ COMPENSATION. ANY ADDITIONAL VISITS
OR REFERRALS MUST BE APPROVED BY THE DISTRICT SAFETY OFFICE OR THE SCHOOL DISTRICTS SERVICING AGENT.
:
DATE:
/
/
TIME REFERRED
AM/PM Signature
of Prin., Foreman, or Immediate Sup.
ARRIVED FOR TREATMENT ON DATE:
/
/
TIME:
AM/FM This a NEW INJURY □ RE-INJURY □
DIAGNOSIS & TREATMENT:
MEDICATIONS:
DISPOSITION OF EMPLOYEE:
□ BACK TO WORK WITH NORMAL DUTIES AS OF DATE
/
/
TIME
AM/PM
IF PATIENT IS RELEASED TO RESTRICTED/MODIFIED DUTIES, THE FOLLOWING RESTRICTIONS SHOULD APPLY FOR
#
DAYS, FOLLOWING WHICH TIME NORMAL DUTIES CAN BE EXPECTED. (CHECK ALL THAT APPLY)
□ BACK TO WORK WITH THE FOLLOWING MODIFIED DUTY RESTRICTIONS RESTRICTED DUTIES AS OF:
DATE
/
/
TIME:
AM/PM
No lifting/carrying over
5lbs
10lbs
25lbs
35lbs
50lbs
No squatting/kneeling
No bending/stooping
No standing/walking
No driving
Must keep wound
clean/dry
Needs to sit/stand as needed
May not work with □ left □ right hand/arm
foot/leg day(s)
May work for
hours/day for
day(s)
week(s)
Other (specify)
COMPLETELY DISABLED FROM WORKING UNTIL
/
/
ADDITIONAL INSTRUCTIONS AND PROGNOSIS
EMPLOYEE WITH MODIFIED DUTY RESTRICTIONS MUST RETURN TO WORK AND MUST NOT EXCEED DOCTORS’
RESTRICTIONS. TREATMENT COMPLETED: DATE:
/
/
TIME:
AM/PM TREATED BY:
(Signature)
MEDICAL PROVIDERS - FAX TO RSKCo (880-5051) - FOR REFERRAL OR PRECERTIFICATION CALL RSKCo (8805071)
EMPLOYEE RETURNED TO WORK
DATE:
/
/
TIME:
AM/PM
REMARKS:
CHECKED IN BY:
Signature
PRINCIPAL or DEPARTMENT SUPERVISOR
SITE NAME AND NUMBER
Fig.4.4-E
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Parent category: Medical