Verification Of Rehabilitation Treatment {WCR-4A} | Pdf Fpdf Doc Docx | Missouri

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Verification Of Rehabilitation Treatment {WCR-4A} | Pdf Fpdf Doc Docx | Missouri

Verification Of Rehabilitation Treatment {WCR-4A}

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 VERIFICATION OF REHABILITATION TREATMENT 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC Injury Number: Employee: Date of Injury: Rehabilitation Facility: SSN: Phone Number: Contact Person: OUTPATIENT TREATMENT Type of rehabilitation received (be specific): Date rehabilitation began: List all dates client has attended therapy: # of days per week therapy ordered: List all dates client cancelled or did not attend scheduled therapy: Please list date employee returned to work: INPATIENT TREATMENT Type of rehabilitation received (be specific): Admission Date: Is therapy continuing at present? List all dates client received therapy: Yes # of days per week therapy ordered: If "No," list discharge date: No List all dates client did not receive scheduled therapy: Please return form to: Fax: 573-522-1623 Phone: 573-526-3876 Mail: Attn: Physical Rehabilitation Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, MO 65102-0058 WCR-4A (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com

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