Get the free Physician ‘Return to Work’ Evaluation Form

This document is a form for physicians to evaluate an injured employee's ability to return to work, detailing their diagnosis, treatment plan, and work capabilities based on physical restrictions.

How to fill out physician return to work

How to fill out Physician ‘Return to Work’ Evaluation Form

1. Obtain the Physician 'Return to Work' Evaluation Form from your healthcare provider or employer.
2. Fill out your personal information, including your name, contact details, and date of birth.
3. Specify the job title and the department where you will be returning.
4. Provide details about your medical condition or any relevant injuries.
5. Include the start date of your medical leave and any previous treatment received.
6. Answer any specific questions related to your capacity to perform job duties.
7. Ensure to have the physician review the form and provide their signature and credentials.
8. Submit the completed form to your employer or designated HR department.

Who needs Physician ‘Return to Work’ Evaluation Form?

1. Employees recovering from an injury or illness who are planning to return to work.
2. Employers who require documentation to assess an employee's readiness to resume work duties.
3. Healthcare providers who need a structured way to communicate an individual's work capacity.

For pdfFiller’s FAQs

What is Physician ‘Return to Work’ Evaluation Form?

The Physician ‘Return to Work’ Evaluation Form is a document used by healthcare providers to assess a patient's readiness to return to work after a medical leave or injury. It captures the patient's medical condition and any necessary work restrictions.

Who is required to file Physician ‘Return to Work’ Evaluation Form?

The form is typically required to be filed by healthcare providers treating patients who have been on medical leave, employers requesting documentation for employees’ return to work, or insurance companies managing worker's compensation claims.

How to fill out Physician ‘Return to Work’ Evaluation Form?

To fill out the form, the physician should complete sections detailing the patient's medical history, assessment results, any physical limitations, and recommendations for the patient's work capacity, including any necessary accommodations.

What is the purpose of Physician ‘Return to Work’ Evaluation Form?

The purpose of the form is to provide a clear and documented assessment of an employee's fitness to return to work, ensure a safe transition back to the workplace, and communicate any necessary accommodations or restrictions to the employer.

What information must be reported on Physician ‘Return to Work’ Evaluation Form?

The form must report the patient's medical condition, the date of evaluation, any work limitations, recommended accommodations, and the physician's signature along with their medical credentials.