Doctor’s Release to Work/Physical
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 ___________________
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 _______________.
Physician’s Signature Date