Form AR- 3 A Carrier, Self Insured Employer, or Third Party Administrator may print its name and address here. Authority: Ark Code Ann. §11-9-516 and AWCC Rule 27 Revised 1-1-2001 3 PHYSICIAN’S REPORT “ First Report “ “ Progress Report Final Report Date of Release From Treatment AWCC File No. Carrier Claim No. Employer Name Claimant Name (Last, First, MI) Employer Ad dress Carrier Or Self-Insured Name Claimant SS No. City State Zip Code 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 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 (date). The claimant can return to work on (date) with no restrictions. The claimant can return to work on (date) with the following temporary restrictions: “ “ “ “ “ No standing for more than No sitting for more than No lifting more than No working more than Other (specify): hours hours pounds hours per day 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. (date) % to the body as a whole, based on % to the (body part). Physician Information License State Physician’s Signature Date of AR Licensure License Number 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