Work Release

WORK RELEASE (800) 552-4007 This form should be returned to: Criminal Injuries Compensation Fund Post Office Box 26927 Richmond, VA 23261 Victim: Address: Claim No. CHECK APPROPRIATE BOX AND FILL IN BLANKS I certify that, because of injuries sustained on : The above-named victim will be constantly totally disabled from returning to work until ____________________. The victim has already been released to return to work. The first day the victim could work was ____________________. The above victim has not been released to return to work. In my opinion, the expected date of release to return to work will be ____________________. The scheduled appointment closest to that date is ____________________, and at that time I will be able to determine if the victim is still totally disabled. Additional Comments__________________________________________________________________ ____________________________________________________________________________________ ____________________________________ Signature of Physician Date This form must be completed by a medical doctor. ____________________________________ Type or Print Name Legibly ____________________________________ Mailing Address ____________________________________ City, State, Zip Code (_____)_____________________________ Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com