This is a template a healthcare provider can use to authorize the fitness and return to employment of an injured employee. The provider can specify whether the employee is fully able to resume working or whether they have restrictions. If the provider only authorizes working with restrictions, they must include the restrictions in the space provided. Additionally, it can be customized to provide for any additional industry specific language that may be necessary. This template can be used by small businesses or other entities that want to provide their healthcare provider with an authorization form to determine the fitness of injured employees.