Physician's return to work and voucher report 2025

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The document is a Physician's Return-to-Work & Voucher Report for employees with injuries occurring on or after January 1, 2013. It outlines the process for physicians to report an employee's permanent and stationary disability status, work capacities, and activity restrictions. The form is mandatory for informing employers about potential work options (regular, modified, or alternative) based on the employee's physical capabilities post-injury. It includes sections for detailing specific limitations and compatibility with job descriptions.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the employee's last name and first name in the designated fields. This identifies the individual for whom the report is being completed.
Fill in the claims administrator and representative details, along with employer information including name, address, city, state, and zip code.
Document the date of injury and claim number accurately to ensure proper tracking of the case.
Indicate whether the employee can return to regular work or if there are specific restrictions. Specify hours for activities such as standing, walking, and sitting.
Detail any lift/carry restrictions by specifying maximum weight limits and duration per day.
Complete sections regarding impaired activities and compatibility with job descriptions if provided. This includes filling out physician's name, role, signature, and date at the end of the form.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (307 Votes)

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