Treating Physicians Progress Report
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Treating Physicians Progress Report Form. This is a Oklahoma form and can be use in Workers Comp.
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Tags: Treating Physicians Progress Report, 4A, Oklahoma Workers Comp,
FORM 4A
SEND COPIES TO:
THIS SPACE FOR COURT USE ONLY
WORKERS’ COMPENSATION COURT
1915 NORTH STILES
OKLAHOMA CITY, OKLAHOMA 73105-4918
1- Employee/Claimant
1 - All Other Parties of Record
In re claim of:
Full Name of Employee (Claimant)
Employee’s Social Security Number
TREATING PHYSICIAN’S PROGRESS REPORT
Name of Employer (Respondent)
FILE NO.
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own
Risk Group, Uninsured
Date of Injury
(Please type or print)
DATE
PROGRESS REPORT:
Is this employee temporarily totally disabled?
NO
YES
I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true,
correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee/Counsel
Address (Number & Street)
Signature of Physician
City
State
Zip Code
Address (Number & Street)
City
Employer/Counsel
Zip Code
Telephone Number of Treating Physician
Address (Number & Street)
City
State
State
Zip Code
Print or type name of Treating Physician
2/06
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