Pennsylvania > Workers Comp
Physicians Affidavit Of Recovery LIBC-497 - Pennsylvania
| Physicians Affidavit Of Recovery Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 Index No. PHYSICIAN'S AFFIDAVIT Plaintiff(s) OF RECOVERY -against- : Social Security Number: Calendar No. Date of Injury: : : MM DD YYYY JUDICIAL SUBPOENA (IF KNOWN) PA BWC Claim Number: Employee First Name Street 1 Street 2 City/Town County Last Name Employer : : Name Street 1 Street 2 Defendant(s) : ...................................................... State Zip Code City/Town Telephone Telephone State FEIN Zip Code THE PEOPLE OF THE STATE OF NEW YORK This is to certify that the aforementioned employee has fully recovered from the following work injury: TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the partyon the date behalf this subpoena able to resume, without limitation, his/her$50 and all damagesof on whose shown above, and is was issued for a maximum penalty of previous occupation sustained as a which occurred result of your failure to comply. on MM DD YYYY . Witness, Honorable , one of the Justices of the Court in day of , 20 This affidavit is based upon anCounty, examination of aforementioned employee performed by the undersigned physician on . MM DD YYYY I attest or affirm that the statements contained herein are true and correct to the best of my knowledge, information and belief. Physician SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS DAY OF SIGNATURE OF NOTARY First Name Signature (Attorney must sign above and type name below) Attorney(s) for Last Name , Date: MM DD YYYY Office and P.O. Address Telephone No.: Facsimile No.: 497 E-Mail Address: 1297-1 Mobile Tel. No.: LIBC-497 REV 12-97 American LegalNet, Inc. www.USCourtForms.com
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