Physicians Report {AR-3}

Form AR- 3 Authority: Ark Code Ann. §11-9-516 and AWCC Rule 27 Revised 1-1-2001 A Carrier, Self Insured Employer, or Third Party Administrator may print its name and address here. 3 Claimant SS No. State Zip Code PHYSICIAN'S REPORT First Report Progress Report Final Report Date of Release From Treatment AWCC File No. Carrier Claim No. Claimant Name (Last, First, MI) Employer Name Employer Ad dress City Carrier Or Self-Insured Name Mailing Addre ss Physician's Report of Injury and Treatment Brief Description of Accident Diagnosis/Treatment Rendered Prognosis/Expected Duration of Treatment If claimant is suffering from any other disabling condition not due to this accident, specify condition: NOTE TO COMPLETING PHYSICIAN: THE BACK SIDE OF THIS FORM MUST ALSO BE COMPLETED, WHERE APPLICABLE. 3 American LegalNet, Inc. www.FormsWorkFlow.com Temporary Disability 3 (date). (date) with no restrictions. (date) with the following temporary restrictions: hours hours pounds hours per day The claimant cannot return to work due to his/her work-related injury until after his/her next appointment with me on (date). The claimant cannot return to work due to his/her work-related injury until The claimant can return to work on The claimant can return to work on No standing for more than No sitting for more than No lifting more than No working more than Other (specify): Permanent Disability The claimant has suffered no permanent impairment due to his/her work-related injury. The maximum medical improvement date (end of healing period): The claimant has suffered a permanent impairment rating of objective and measurable findings such as: The claimant has suffered a permanent impairment rating of The claimant has suffered facial or head disfigurement. The claimant has suffered permanent, total disability. Physician Information (date) % to the body as a whole, based on % to the (body part). License State Date of AR Licensure License Number Physician's Signature Physician's Printed or Typewritten Name Date Form 3 is approved by the Arkansas Workers' Compensation Commission, P.O. Box 950, Little Rock, Arkansas 72203-0950, for use by providers to report the status of a patient's treatment. Form 3 should be sent by the medical provider to the company handling the workers' compensation case for the employer. American LegalNet, Inc. www.FormsWorkFlow.com