Physicians Return-To-Work And Voucher Report (On Or After 1-1-13) {DWC AD 10133.36}

PHYSICIAN'S RETURN-TO-WORK & VOUCHER REPORT FOR INJURIES OCCURRING ON OR AFTER 1/1/13. This is a mandatory California Division of Workers’ Compensation (DWC) form used for injuries occurring on or after January 1, 2013. It must be completed by the first physician—either a Primary Treating Physician (PTP), Agreed Medical Evaluator (AME), or Qualified Medical Evaluator (QME)—who determines that the employee’s disability from all claimed conditions is permanent and stationary (or at maximum medical improvement) and has resulted in permanent partial disability. The purpose of this form is to inform the employer and claims administrator of the employee’s work capacities, activity restrictions, and job compatibility for regular, modified, or alternative work. If a job description is provided, the physician must assess whether the employee’s restrictions align with the physical requirements of that position. The form specifies work limitations such as lifting, standing, walking, grasping, bending, or sitting and may also include psychiatric or environmental restrictions. This form is a mandatory attachment to the first medical report confirming permanent partial disability and is used for Supplemental Job Displacement Benefit (SJDB) voucher purposes. www.FormsWorkflow.com