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RETURN TO WORK FORM
RETURN TO WORK FORM. Patients Name (last, first, middle initial). Date of Injury. Employer Name Address. Nature of Injury. TO BE COMPLETED BY MEDICAL
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release and return to work - medical certification
PLEASE NOTE: A Medical Certification authorizing return to work WITHOUT LIMITATION (FULL RELEASE) may be required at the time Employee is released to return to
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Medical Record Standard - Stronger security is required
Requests for release of medical records must be accompanied by written consent from the worker. In certain circumstances information may be released as mandated
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