Oklahoma > Workers Comp
Treating Physicians Progress Report 4A - Oklahoma
| Treating Physicians Progress Report Form. This is a Oklahoma form and can be used in Workers Comp . |
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FORM 4A SEND COPIES TO: 1- Employee/Claimant 1 - All Other Parties of Record In re claim of: Full Name of Employee (Claimant) WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918 THIS SPACE FOR COURT USE ONLY Employee's Social Security Number TREATING PHYSICIAN'S PROGRESS REPORT Name of Employer (Respondent) FILE NO. Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Date of Injury (Please type or print) DATE PROGRESS REPORT: Is this employee temporarily totally disabled? 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. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Employee/Counsel Address (Number & Street) Signature of Physician City State Zip Code Address (Number & Street) Employer/Counsel City State Zip Code Address (Number & Street) Telephone Number of Treating Physician State Zip Code City Print or type name of Treating Physician 2/06 American LegalNet, Inc. www.USCourtForms.com
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