Utah > Workers Compensation
Attending Physicians Statement 043 - Utah
| Attending Physicians Statement Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 043 . ATTENDING PHYSICIAN'S STATEMENT PLEASE PRINT OR TYPE TO THE APPLICANT: Prior to mailing this form to the last physician who treated you in the state of Utah, please complete the following: Your Complete Name: _______________________________________________________________________ Your Complete Current Mailing Address: _________________________________________________________ ___________________________________________________________________________________________ Date of Injury: Employer Social Security Number: __________________________ Insurance Carrier _______________________________ TO THE PHYSICIAN: Please complete this form and mail it to the Labor Commission, Division of Industrial Accidents, 160 East 300 South, 3rd Floor, P.O. Box 146610, Salt Lake City, UT 84114-6610, (801) 530-6800, AS SOON AS POSSIBLE. 1. Condition of Employee when last examined: __________________________________________________ Date of Last Examination: _________________________________________________________________ 2. If Applicant is not released to return to work at time of last examination, please provide your best professional opinion as to the following: a. Estimated date of stabilization or return to work: ______________________________________________ b. Additional medical treatment required: ______________________________________________________ c. Probability and extent of permanent partial impairment: ________________________________________ 3. If attending physician is responsible for referring injured employee to another physician, clinic, or hospital, please indicate to which doctor, clinic, or hospital and provide the address thereof. Please give a brief explanation of your referral. _____________________________________ Printed Name of Attending Physician _______________________________________ Signature of Attending Physician _________________________________________________________________________________________ Number, Street and Suite # _________________________________________________________________________________________ City/State/Zip Date of this Report: ______________________ Official Form 043 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
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