PHYSICIAN'S NOTICE OF RELEASE TO WORK Submit to insurer within three (3) days of release to work with a copy to the employee and his or her attorney. DWC/MAB File # Employee/Patient Information: Social Security # Name Address City, State, Zip Phone Date of Birth Injury Date: Insurance Carrier: Name Address City, State, Zip Phone Insurer's File # Employer Information: FEIN # Name Address City, State, Zip Phone Adjusting Company: Name Address City, State, Zip Phone If the insurer is not known, contact the Division of Workers' Compensation at (401) 462-8100. Section 28-33-8(b) of the RI Workers' Compensation Act provides for a $20.00 fee to be charged for the timely filing of this form. This medical report is rendered pursuant to Section 28-33-8 of the RI Workers' Compensation Act. This is to certify that the above named employee is able to return to work on To (check one) _ Regular duty, no restrictions __ Modified duty, limitations as follow: Alternate standing/sitting No work involving use of right/left ___________ Sit down work only Keep wound clean and dry Other _________________________________ _____________________________________ Indicate modified duty restrictions: __ __ __ __ __ __ No operating heavy machinery or vehicles No repetitive climbing ladders or stairs May lift up to ________ pounds only No reaching above shoulders No repetitive twisting, bending, squatting No repetitive stooping, kneeling __ __ __ __ __ __ The patient will require no further medical items or medical services associated with this claim. This certification is based on the medical examination performed on Physician's signature Physician's name Treatment facility Physician's Assistant Signature Supervising Physician's Name Physician's Address Form DWC-27/28 (7/09) RI Department of Labor & Training, Division of Workers' Compensation Date American LegalNet, Inc. www.FormsWorkFlow.com