RETURN TO WORK RELEASE

(Workers' Compensation Medical Authorization)

[// GUIDANCE: This form documents a physician's clearance for an injured worker to return to employment. Many states require specific forms (e.g., California Physician's Return-to-Work & Voucher Report). This template is designed for physician completion and employer use in accommodating returning workers.]

SECTION 1: DOCUMENT HEADER

DATE OF RELEASE: [DATE]

CLAIM NUMBER: [CLAIM NUMBER]

TYPE OF RELEASE:
☐ Full Duty Release - No Restrictions
☐ Modified/Light Duty Release - With Restrictions
☐ Conditional Release - Subject to Accommodation
☐ Progressive Return - Graduated Increase in Duties

SECTION 2: PATIENT/EMPLOYEE INFORMATION

Patient Name: [FULL NAME]

Date of Birth: [DATE]

Social Security Number (Last 4): XXX-XX-[LAST 4]

Date of Injury: [DATE]

Employer: [EMPLOYER NAME]

Job Title: [JOB TITLE]

SECTION 3: PHYSICIAN INFORMATION

Physician Name: [NAME], [CREDENTIALS]

Specialty: [SPECIALTY]

License Number: [NUMBER]

Practice Name: [PRACTICE NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Fax: [FAX NUMBER]

SECTION 4: MEDICAL RELEASE DETAILS

4.1 Release Status

Effective Date of Release: [DATE]

Medical Status:
☐ Patient has reached Maximum Medical Improvement (MMI)
☐ Patient is improving but has not reached MMI
☐ Patient requires ongoing treatment while working
☐ Patient is medically stable for work activities within restrictions

4.2 Work Capacity Determination

This patient is cleared to return to:

☐ FULL DUTY
The patient may return to their regular job duties without any restrictions effective [DATE].

☐ MODIFIED DUTY WITH RESTRICTIONS
The patient may return to work with the restrictions specified below effective [DATE] through [END DATE OR "UNTIL FURTHER NOTICE"].

☐ PART-TIME/REDUCED HOURS
The patient may work [NUMBER] hours per day, [NUMBER] days per week.

☐ GRADUATED RETURN
The patient should gradually increase work activities as follows:
Week 1: [HOURS/RESTRICTIONS]
Week 2: [HOURS/RESTRICTIONS]
Week 3: [HOURS/RESTRICTIONS]
Week 4: [HOURS/RESTRICTIONS]

SECTION 5: WORK RESTRICTIONS AND LIMITATIONS

[// GUIDANCE: Complete this section for modified duty releases. Be specific to enable employer accommodation.]

5.1 Physical Restrictions

Lifting/Carrying:
☐ No restrictions
☐ No lifting over [___] pounds
☐ No lifting over [___] pounds above shoulder height
☐ No lifting over [___] pounds below knee level
☐ No repetitive lifting
☐ Two-person lift required for items over [___] pounds

Pushing/Pulling:
☐ No restrictions
☐ No pushing/pulling over [___] pounds of force

Posture and Movement:

Upper Extremity Restrictions:

Lower Extremity Restrictions:
☐ No restrictions
☐ No prolonged standing (limit to [___] minutes at a time)
☐ Limit walking to [___] feet/yards at a time
☐ No climbing
☐ No operating foot controls
☐ Use of assistive device required: [SPECIFY]

5.2 Environmental Restrictions

☐ No restrictions on work environment

Temperature:
☐ Avoid extreme heat (over [___]°F)
☐ Avoid extreme cold (under [___]°F)
☐ Avoid temperature fluctuations

Exposure:
☐ Avoid dust/particulates
☐ Avoid fumes/gases
☐ Avoid chemicals: [SPECIFY]
☐ Avoid loud noise
☐ Avoid vibration
☐ Avoid heights over [___] feet
☐ Avoid confined spaces

5.3 Work Schedule Restrictions

Hours:
☐ No restrictions on hours
☐ Maximum [___] hours per day
☐ Maximum [___] hours per week
☐ No overtime
☐ Mandatory rest breaks every [___] hours for [___] minutes

Shifts:
☐ No restrictions on shifts
☐ Day shift only
☐ No rotating shifts
☐ No night shifts

5.4 Activity-Specific Restrictions

☐ No driving (work-related)
☐ May drive for [___] minutes maximum
☐ No operating heavy machinery
☐ No operating power tools
☐ No work at heights
☐ No working alone
☐ Other: [SPECIFY]

5.5 Additional Accommodations Recommended

[DESCRIBE ANY ADDITIONAL ACCOMMODATIONS]

Examples:
- Ergonomic workstation
- Sit/stand desk
- Frequent position changes
- Specific seating requirements
- Anti-fatigue mat
- Modified tools/equipment
____________________________________________________________________________

____________________________________________________________________________

SECTION 6: DURATION OF RESTRICTIONS

Restrictions Are:
☐ Temporary - Expected to be lifted on approximately [DATE]
☐ Temporary - Until next medical evaluation on [DATE]
☐ Temporary - Duration unknown, reassess in [___] weeks
☐ Permanent - These restrictions are expected to be permanent

Next Re-Evaluation Date: [DATE]

SECTION 7: ONGOING MEDICAL TREATMENT

Will Patient Require Ongoing Medical Treatment While Working?
☐ No
☐ Yes - Specify below

Type of Ongoing Treatment:
☐ Physical Therapy: [___] times per week
☐ Occupational Therapy: [___] times per week
☐ Medical Follow-up: Every [___] weeks
☐ Medication Management
☐ Other: [SPECIFY]

Treatment Schedule Accommodations Needed:
[DESCRIBE ANY TIME-OFF NEEDS FOR MEDICAL APPOINTMENTS]

SECTION 8: JOB ANALYSIS RESPONSE (EMPLOYER COMPLETION)

[// GUIDANCE: This section to be completed by employer after review of restrictions]

8.1 Essential Job Functions Review

Job Title: [JOB TITLE]

Can the employee perform the essential functions of their regular job within the stated restrictions?
☐ Yes - Employee can perform all essential functions
☐ No - Essential functions exceed stated restrictions
☐ Partial - Employee can perform some essential functions

8.2 Modified Duty Availability

Is modified/light duty work available within restrictions?
☐ Yes - Modified duty position available
☐ No - No modified duty available at this time

If Yes, describe modified duty position:

Position Title: [TITLE]
Department: [DEPARTMENT]
Supervisor: [NAME]
Start Date: [DATE]
Duration: [DURATION]

Description of Modified Duties:
____________________________________________________________________________

____________________________________________________________________________

8.3 Employer Certification

Employer Representative: [NAME]

Title: [TITLE]

Date: [DATE]

Signature: _________________________________

SECTION 9: PHYSICIAN CERTIFICATION

I, [PHYSICIAN NAME], [CREDENTIALS], certify that:

☐ I have examined the patient on [DATE].

☐ Based on my examination and review of medical records, the patient is medically cleared to return to work as indicated above.

☐ The restrictions specified above are medically necessary to prevent re-injury or worsening of the patient's condition.

☐ These restrictions are based on objective medical findings.

☐ I have reviewed the patient's job description/job analysis: ☐ Yes ☐ No ☐ Not Provided

Physician Signature: _________________________________

Printed Name: [NAME], [CREDENTIALS]

Date: [DATE]

License Number: [NUMBER]

SECTION 10: EMPLOYEE ACKNOWLEDGMENT

I, [EMPLOYEE NAME], acknowledge that:

☐ I have received a copy of this Return to Work Release.

☐ I understand the work restrictions placed on me by my physician.

☐ I agree to abide by these restrictions and will not perform activities outside the stated limitations.

☐ I will immediately report any increase in symptoms or pain to my supervisor and treating physician.

☐ I understand that failure to follow these restrictions may result in re-injury and may affect my workers' compensation benefits.

☐ I understand that I should notify my employer and physician if the modified duty position requires me to exceed these restrictions.

Employee Signature: _________________________________

Date: [DATE]

SECTION 11: IMPORTANT NOTICES

For the Employee:

1. Follow Your Restrictions: You must not perform work activities that exceed the restrictions listed in this release. Doing so may result in re-injury and could affect your eligibility for workers' compensation benefits.

2. Report Problems Immediately: If you experience increased pain, new symptoms, or feel that your work duties are exceeding your restrictions, notify your supervisor immediately and contact your treating physician.

3. Attend Medical Appointments: Continue to attend all scheduled medical appointments and follow your treatment plan.

4. Communicate with Your Employer: Work with your employer to ensure your modified duty assignment stays within your restrictions.

For the Employer:

1. Accommodate Restrictions: The employer should make reasonable efforts to accommodate the stated restrictions.

2. Monitor the Employee: Supervisors should ensure the employee's duties remain within the stated restrictions.

3. Document Modified Duty: Maintain records of modified duty assignments and any issues that arise.

4. Report Changes: Notify the insurance carrier and treating physician of any changes in the employee's work status.

State-Specific Notices:

[// GUIDANCE: Insert applicable state-specific requirements]

California: If modified/alternative work is not offered within 60 days of receipt of a Physician's Return-to-Work & Voucher Report, the employee may be entitled to a Supplemental Job Displacement Benefit (SJDB) voucher.

Texas: The employer must notify the Division of Workers' Compensation if modified duty is offered and refused.

[YOUR STATE]: [INSERT STATE-SPECIFIC NOTICE]

DISTRIBUTION

☐ Original to Employee
☐ Copy to Employer/HR Department
☐ Copy to Supervisor
☐ Copy to Workers' Compensation Insurance Carrier
☐ Copy retained in Physician's Medical Records

[END OF DOCUMENT]