Physicians Rehabilitation Information Sheet {WCR-1A} | Pdf Fpdf Doc Docx | Missouri

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Physicians Rehabilitation Information Sheet {WCR-1A} | Pdf Fpdf Doc Docx | Missouri

Physicians Rehabilitation Information Sheet {WCR-1A}

This is a Missouri form that can be used for Workers Comp.

Alternate TextLast updated: 7/11/2012

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS PHYSICIAN'S REHABILITATION INFORMATION SHEET 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC The purpose of this form is to gather additional information to determine eligibility for physical rehabilitation benefits for the indicated injured employee. Please note the date of injury and complete the form according to the patient's condition at the time of the injury or initiation of rehabilitation. (The condition at the time of injury and rehabilitation may be different from present condition). Employee: Employer: Injury No: Insurer's No: Attending Physician: Complete Mailing Address: Phone Number: Rehabilitation has been received: Rehabilitation is currently being received: Rehabilitation is expected to be received: No rehabilitation received or indicated: Yes Yes Yes Yes No No No No Insurance contact person for this claim: Name: Phone Number: Return completed form to: Fax: 573-522-1623 Mail: Attn: Physical Rehabilitation Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, MO 65102-0058 WCR-1A (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com

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