Instructions: Edit any information below and click "Export Word" to generate the document.
Dear
,
Your client,
,
has been identified as an appropriate candidate for our Virtual Work from Home light
duty program. This program has been developed by [[formData.jobSiteName]] in an effort to support our injured employees as they progress in recovery; it is temporary and transitional. While participating in the program, your client will be returned to employer payroll and all applicable pre-injury benefits will resume.
[[formData.employeeName]] will be volunteering with
,
in support of their mission. While participating in the program, they will be tasked with job duties within their restrictions, including:
.
Training will be provided by [[formData.npoName]].
Your client will be loaned the equipment necessary to complete the assigned tasks, and Transitional Work Solutions (TWS) will communicate with [[formData.employeeName]] to provide technical support as an agent of [[formData.jobSiteName]]. Communication with your client will be limited to technical support only. TWS will function strictly as a conduit to [[formData.npoName]]. Please note that should you not consent your client will be limited to technical support by reviewing documentation provided only.
We appreciate your authorizing consent for TWS to communicate with your client by signing below agreement.
Please reach out to me should you have any questions or concerns.
Best Regards,
Consent to Communicate
I hereby authorize Transitional Work Solutions (TWS), through its appropriate personnel to communicate with [[formData.employeeName]] regarding technical support and IT Help while participating in the [[formData.jobSiteName]] Virtual Work from Home light duty program. Communication will be limited to IT support; no information regarding [[formData.employeeNamePossessive]] injury, claim, or work will be discussed.
| Attorney Name (Print) | ||
| Attorney Name (Sign) | Date | |