DOCTORS ESTIMATE OF FUTURE MEDICAL EXPENSES (Date) (Doctors name) (Doctors address) In re: vs. Claimant Employer/Carrier Date of Accident: _________________ Dear Dr. ________ : This office represents the employer/carrier claimant in the above-referenced claim. A settlement of this workers compensation claim has been proposed that would close the right of the claimant to receive future medical treatment at the expense of the employer/carrier. Please provide me with the following information as it relates to the claimants injuries which resulted from this industrial accident. 1. Future medical expenses have been estimated at $____________. (amount proposed in washout) Is this estimate reasonable? ____________ If not, please explain _________________________________________ ________________________________________________________________ 2. Please give your opinion as to future medical care due to the injuries claimed in this industrial accident ___________________ ________________________________________________________________ 3. Does the claimant have any work restrictions? ______________ ________________________________________________________________ 4. Date of Maximum Medical Improvement ________________________ _____________________ _______________________________ (date) (doctors signature) Upon completion, please fax or mail this form to my attention. Sincerely, __________________, Esquire American LegalNet, Inc. www.USCourtForms.com