Return To Work Doctor Medical Form Template

					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.
                                         Return to Work Form
                  To be completed by healthcare provider prior to returning to work.


Fitness for Duty:

I have examined _________________________________ and can certify that he/she
is:


___ fully able to resume working as of __________________________.
                                                  Date

 ___ able to return to work on __________________ with the following restrictions:
                                      Date
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


______________________________________                           __________________________
Healthcare Provider’s Signature                                        Type of Practice

______________________________________                           __________________________
Printed Name of Healthcare Provider                                    Telephone Number

______________________________________                           __________________________
Address                                                                 Date




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Description: 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.
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