Instructions: Edit any information below and click "Export Word" to generate the document.
Dr.
RE:
W.C. No.:
Carrier No.:
Dear Dr.
:
Our employee, [[formData.employeeName]], is currently unable to perform the regular duties of [[formData.hisHer]] job.
has identified a modified job position, which appears to be within [[formData.hisHer]] current restrictions. Please review the job duties and schedule below and provide your
opinion whether
is capable of performing the job duties at this time. If you believe that [[formData.employeeFirstName]] can perform the job duties,
please approve the job offer by signing this letter below and immediately returning this form to our office. We appreciate your time and expertise spent in addressing this issue.
Work Schedule
Detailed Description of Job Duties: (Attached detailed job description)
Thank you,
cc:
[[formData.employeeName]], Claimant
/
, Claimant Attorney
SIGNATURE OF APPROVAL
I have reviewed the above job offer and it is my opinion that [[formData.employeeName]] has the physical capacity and ability to perform all the job duties offered. I am approving this job offer by providing my signature below.
Physician's Signature
Date