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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 .
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CC-FORM-5 SEND COPIES TO: 1- Employee/Claimant 1 - All Ot e a e o Re o In e laim o : Full Name o Employee (Claimant) WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 Created 2-1-14 THIS S ACE FOR COMMISSION USE ONLY PHYSICIAN'S REPORT ON RELEASE AND RESTRICTIONS Employee' So ial Se u ity Numbe (LAST 4 DIGITS ONLY) XXX-XX-________________________ Name o Employe (Re pon ent) COMMISSION FILE NO. Employe ' In u an e Ca ie , e mit # o Commi ion App ove In ivi ual Sel -In u e o Own Ri k G oup, Unin u e Date o Inju y Diagno i a t o Bo y Date o Exam I. RELEASED FOR WORK? YES, elea e to: Regula Wo k ( ate): Mo i e Wo k ( ate): Give Re t i on ( omplete Se on II) NO, laimant emain tempo a ily totally i able . II. RESTRICTIONS (check all that apply and describe fully under number 8 below) No Restric ons Permanent Restric ons Temporary Restric ons 1.___Re t i te li ing (maximum weig t in poun ) 10___ 5___ 50___ Ot e ____ F e uen y ___________ .___Re t i te pu ing/pulling o _________ lb . 3.___Re t i te ea ing: above e t ove ea away om bo y 4.___Re t i te to one- an e uty. No u e o : Rig t an Le an 5.___Re t i te walking tan ing i ng ( e ibe ully) pa al weig t bea ing ( e ibe ully) ben ing twi ng 6.___Wea plint at: All Time Wo k Nig t ( e ibe ully) 7.___DO NOT: Ope ate Ma ine y C awl Kneel S uat D ive any Ve i le Climb Ben Stoop Twi t FULLY DESCRIBE RESTRICTIONS (i.e. u a on, natu e o limita on, et .) Supplement wit ext a page i nee e : 8. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ III. MEDICAL & REHABILITATION A. I on nuing me i al maintenan e nee e NO YES I YES, e ibe ully, in lu ing ate o next appointment. Supplement wit ext a page i nee e . B. I vo a onal e abilita on in i ate (i.e. A a e ult o t e inju y, i t e employee unable to pe o m wo k o w i t e pe on a p eviou t aining o expe ien e ) 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 com lete Any erson who commits workers com ensa on fraud, u on convic on, shall be guilty of a felony unishable by im risonment, a fine or both I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Employee/Coun el Signe t i ________ ay o ________________________________, _________. A e (Numbe & St eet) Signatu e o y i ian City State Zip Co e A e (Numbe & St eet) City Employe /Coun el State Zip Co e Telep one Numbe o A e (Numbe & St eet) y i ian int o type name o City State Zip Co e y i ian American LegalNet, Inc. www.FormsWorkFlow.com
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