Doctor Work Release Forms - PDF

							                          Doctor’s Release to Work/Physical
                          Capacities Evaluation
                          The Doctor’s Release to Work must be presented to and completed by the assigned health care
                          provider upon an injured employee’s initial visit and faxed to the Wichita Falls Office within 24
                          hours after accident/injury notification.




Please help us serve our employee’s needs by completing this form.


Employee’s Name __________________________                                        Date ___________________

Diagnosis _________________________________

    Discharged with no limitations
    Discharged date                      with the following limitations:




    Resume regular duties after                               days or,

    Employee will be reevaluated on ______________.

    Employee is totally incapacitated at this time; and will be reevaluated on _______________.


Additional Comments:




______________________________                                         _______________
Physician’s Signature                                                  Date