Physician Authorization Of Supplemental Disability {3531}

PHYSICIAN AUTHORIZATION OF SUPPLEMENTAL DISABILITY Worker: You are responsible for getting this form completed by your physician to continue receiving supplemental disability. r e k r Worker name Date of birth o W Date of injury Claim number Primary insurer Definitions: Primary job means the job at which the injury occurred. Secondary job means any other job held by the worker at the time of injury. Temporary disability means wage loss replacement for the primary job. Supplemental disability means wage loss replacement for the secondary job(s) that exceeds the temporary disability. Physicians name (printed) Phone number Address City State ZIP Yes (date): Medically stationary? No (anticipated date): Regular work authorized start (date): Worker/patient Modified work authorized from (date): through (date, if known): n ability to work: a i No work authorized from (date): through (date, if known): c i s y Restrictions: h P Primary job I certify that these restrictions apply to : Secondary job Physicians signature Date 440-3531 (9/03/DCBS/WCD/WEB)