Physicians Affidavit Of Recovery {LIBC-497}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION PHYSICIAN222S AFFIDAVIT002 OF RECOVERY002 First name Last name Date of birth Address Address City/Town State ZIP County Telephone Name Address Address City/Town State ZIP County Telephone FEIN EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURYWCAIS CLAIM NUMBER -- --MM DD YYYY EMPLOYEE EMPLOYER This is to certify that the aforementioned employee has fully recovered from the following work injury: which occurred on the date shown above, and is able to resume, without limitation, his/her previous occupation ofon . --MM DD YYYY . --MM DD YYYY PHYSICIAN SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS DAY OF , First name Last name Signature MM -DD -YYYY Email Services Hearing Impaired *497* Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com