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Return to Work Form Medical Authorization Name of Patient Patient Phone Name Title of Health Care Provider Physician Phone Dates of Treatment/Office Visits Physician Fax 1. Following review of the position description I certify that in my medical opinion this patient is unable to work from begin date to end date. 2. For Workers Compensation Leaves Only a. May return to alternate duty on begin date to end date. If patient can return to alternate duty you must...
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