Rhode Island > Workers Comp > Department Of Labor And Training > Medical
Physicians Notice Of Release To Work DWC-27-28 - Rhode Island
| Physicians Notice Of Release To Work Form. This is a Rhode Island form and can be used in Medical Department Of Labor And Training Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PHYSICIANS NOTICE OF RELEASE TO WORK TO BE SUMITTED TO INSURER WITHIN THREE (3) DAYS OF RELEASE TO WORK WITH A COPY TO THE EMPLO YEE AND HIS OR HER ATTORNEY DWC/MAB #: _________________________ IN SURERS #:_______________________ EMPLOYEE INFORMATION: EMPLOYER INFORMATION: Social security # ______________________________ FEIN # ______________________________________ Name ______________________________________ Name _______________________________________ Address ____________________________________ Address _____________________________________ City _________________ State_____ Zip _________ City _________________ State_____ Zip _________ Phone _____________________ DOB ____________ Phone ______________________________________ INSURANCE CARRIER: ADJUSTING COMPANY: Name ______________________________________ Name _______________________________________ Address ____________________________________ Address _____________________________________ City _________________ State_____ Zip _________ City _________________ State_____ Zip _________ Phone ______________________________________ Phone ______________________________________ Injury Date __________________________________ IF THE IDENTITY OF THE INSURER IS UNKNOWN, CONTACT THE DIVISION OF WORKERS COMPENSATION AT (401) 462-8116 FOR THE INFORMATION. SECTION 28-33-8(b) OF THE RHODE ISLAND WORKERS COMPENSATION ACT PROVIDES FOR A $20.00 FEE TO BE CHARGED FOR THE TIMELY FILING OF THIS FORM. This medical report is rendered pursuant to Section 28-33-8 of the Rhode Island Workers Compensation Act. This is to certify that the above named employee is able to return to work on __________________________, as follows: Check one: __ A. Regular duty, no restrictions __ B. Modified duty, limitations as follow: Please check the appropriate box(s): __ No operating heavy machinery or vehicles __ No repetitive climbing ladders or stairs __ May lift up to ________ pounds only __ No reaching above shoulders __ No repetitive twisting, bending, squatting __ No repetitive stooping, kneeling __ Alternate standing/sitting __ No work involving uses of right/left ____________ __ Sit down work only __ Keep wound clean and dry __ Other ______________________________________________________________________ This certification is based on medical examination performed on _____________________. Physicians Signature__________________________________________ Date ________________________________ Physicians Name ________________________________ Treatment Facility ______________________________ Physicians Assistant Signature _______________________________________________________________________ Supervising Physicians Name ________________________________________________________________________ Physicians Address ________________________________________________________________________________ DWC-27/28 (4/02) RI Department of Labor & Training, Division of Workers Compensation
|
|||||||
