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Physicians Report On Release And Restrictions CC-Form-5 - Oklahoma

Physicians Report On Release And Restrictions Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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CC-FORM-5 SEND COPIES TO: 1- Employee/Claimant 1 - All Other Parties of Record In re claim of: Full Name of Employee (Claimant) WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 Revised 2-2-16 THIS SPACE FOR COMMISSION USE ONLY PHYSICIAN'S REPORT ON RELEASE AND RESTRICTIONS Employee's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-________________________ Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk Group, Uninsured COMMISSION FILE NO. Date of Injury Part of Body Diagnosis Date of Exam I. RELEASED FOR WORK? YES, released to: Regular Work (date): Modified Work (date): Give Restrictions (complete Section II) NO, claimant remains temporarily totally disabled. 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. Is continuing medical maintenance needed? NO YES If YES, describe fully, including date of next appointment. 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 work for which the person has previous training or experience?) 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 punishable by imprisonment, a fine or both. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Employee/Counsel Address (Number & Street) Signed this ________day of________________________________, _________. 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 American LegalNet, Inc. www.FormsWorkFlow.com
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