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Physicians Return-To-Work And Voucher Report (On Or After 1-1-13) DWC AD 10133.36 - California
| Physicians Return-To-Work And Voucher Report (On Or After 1-1-13) Form. This is a California form and can be used in General Workers Comp . |
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Physician's Return-to-Work & Voucher Report For injuries occurring on or after January 1, 2013 The Employee is P&S from all conditions and the injury has caused permanent partial disability Employee Last Name Employee First Name MI Date of Injury Claims Administrator: Claims Representative Employer Name: Employer Street Address: Employer City: State Zip Code Claim No. The Employee can return to regular work The Employee can work with restrictions: 1-2 hours Stand Walk Sit Bend Squat Climb Twist Reach Crawl Drive Reach R/L/Bilat Hand(s) (circle): R/L/Bilat Hand(s) (circle): Grasp Push/Pull 2-4 hours 4-6 hours 6-8 hours None Lift/Carry Restrictions: May not lift/carry at a height of more than lbs. for more than hours per day. Other Restrictions: If a Job Description has been provided, please complete: Job Description provided of: Job Title: Work Location Regular Modified Alternative Work Are the Work Duties compatible with the activity restrictions set forth in the provided job description? Yes No, explain below Physician's Name Role of Doctor (PTP, QME, AME) Date American LegalNet, Inc. www.FormsWorkFlow.com Physician's Signature State of California, Division of Workers' Compensation Retraining and Return to Work Unit Physician's Return-to-Work & Voucher Report Instructions For injuries on or after January 1, 2013 DWC - AD 10133.36 Who is responsible for filling out this form? The first physician who finds that the disability from all conditions for which compensation is claimed has become permanent and stationary (or has reached maximum medical improvement) and finds that the injury has caused permanent partial disability. The physician can be the primary treating physician, a Qualified Medical Evaluator, or an Agreed Medical Evaluator. What is the purpose of this form? The purpose of the form is to fully inform the employer of the work capacities and activity restrictions resulting from the injury that are relevant to potential regular work, modified work, or alternative work. The information contained on the form is for voucher purposes and is not considered in any permanent impairment rating or any permanent disability indemnity. Is this a mandatory form? This is a mandatory attachment to the first medical report finding that the disability from all conditions for which compensation is claimed has become permanent and stationary and that the injury has caused permanent partial disability. This form should be attached to a comprehensive medical-legal evaluation and does not replace such comprehensive medical-legal evaluations. When does the form need to be completed? This form does not need to be completed until all conditions for which compensation is claimed have become permanent and stationary. If the employer or claims administrator has provided the physician with a job description providing physical requirements of the employee's regular work, proposed modified work, or proposed alternative work, the physician shall evaluate and describe in the form whether the work capacities and activity restrictions are compatible with the physical requirements set forth in that job description. The bottom portion of the form does not need to be completed if the physician has not been provided with a job description. Completing the employee's work restrictions: The physician should indicate work restrictions in terms of how many hours a particular activity can be performed during an 8hour work day. For hand restrictions, the physician should indicate whether the restrictions are for the right hand, left hand, or both. Other Restrictions can include psychiatric restrictions, chemical exposure, use of equipment, or any other restrictions. The space can also be used to further clarify or explain any of the checked restrictions. How does the employer receive the form? The claims administrator shall forward the form to the employer. DWC AD Form 10133.36 (Effective 1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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