Physician'S Report On Release And Restrictions
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1FORM 5
COURT OF EXISTING CLAIMS
C. 11/02/2015
1915 NORTH STILES
THIS SPACE FOR COURT USE ONLY
SEND COPIES TO:
OKLAHOMA CITY, OK 73105-4918
1- Employee/Claimant
1 - All Other Parties of Record
PHYSICIAN’S REPORT ON RELEASE AND RESTRICTIONS
In re claim of:
Full Name of Employee (Claimant)
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
WCC FILE NO.
Name of Employer (Respondent)
Date of Injury
Diagnosis
Employer’s Insurance Carrier, Permit # for Court Approved Individual
Self-Insured or Own Risk Group, Uninsured
Part of Body
Date of Exam
YES, released to:
Regular Work (date):
Modified Work (date):
Give Restrictions (complete Section II)
RELEASED
I.
FOR
NO, claimant remains temporarily totally disabled.
WORK?
II.
RESTRICTIONS (check all that apply and describe fully under number 8 below)
No Restrictions
Permanent Restrictions
Temporary Restrictions
1.___Restricted lifting (maximum weight in pounds) 10___ 25___ 50___ Other____
Frequency ___________
2.___Restricted pushing/pulling of _________ lbs.
3.___Restricted reaching:
above chest
overhead
away from body
4.___Restricted to one-handed duty. No use of:
Right hand
Left hand
5.___Restricted
walking
standing
sitting (describe fully)
partial weight bearing (describe fully)
bending
twisting
6.___Wear splint at:
All Times
Work
Night (describe fully)
7.___DO NOT:
Operate Machinery
Crawl
Kneel
Squat
Drive any Vehicle
Climb
Bend
Stoop
Twist
8.
FULLY DESCRIBE RESTRICTIONS (i.e. duration, nature of limitation, etc.) Supplement with extra pages if needed:
_______________________________________________________________________________________________________________________
III.
MEDICAL & REHABILITATION
A. 1. Is Additional active medical treatment recommended? NO
YES
If YES, describe fully, including date of next appointment. Supplement with
extra pages if needed. ____________________________________________________________________________________________________
2. Is continuing medical maintenance recommended? NO
YES
If YES, describe fully, including recommended medications, supportive
devices, etc. Supplement with extra pages if needed. ___________________________________________________________________________
B.
Is Vocational rehabilitation indicated? (i.e. As a result of the injury, is the employee unable to perform the same occupational duties the employee __
was performing before the injury?) NO
YES
I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief,
they are true, correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a
felony.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee/Counsel
Signed this__________________day of__________________, ______.
Address (Number & Street)
Signature of Physician
City
State
Zip Code
Address (Number & Street)
Employer/Counsel
City
State
Zip Code
Address (Number & Street)
Telephone Number of Physician
City
State
Zip Code
Print or type name of Physician
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