Print Form Form 043 . ATTENDING PHYSICIAN'S STATEMENT PLEASE PRINT OR TYPE TO THE APPLICANT: Prior to mailing this form to the last physician who treated you in the state of Utah, please complete the following: Your Complete Name: _______________________________________________________________________ Your Complete Current Mailing Address: _________________________________________________________ ___________________________________________________________________________________________ Date of Injury: Employer Social Security Number: __________________________ Insurance Carrier _______________________________ TO THE PHYSICIAN: Please complete this form and mail it to the Labor Commission, Division of Industrial Accidents, 160 East 300 South, 3rd Floor, P.O. Box 146610, Salt Lake City, UT 84114-6610, (801) 530-6800, AS SOON AS POSSIBLE. 1. Condition of Employee when last examined: __________________________________________________ Date of Last Examination: _________________________________________________________________ 2. If Applicant is not released to return to work at time of last examination, please provide your best professional opinion as to the following: Date of this Report: a. Estimated date of stabilization or return to work: ______________________________________________ b. Additional medical treatment required: ______________________________________________________ c. Probability and extent of permanent partial impairment: ________________________________________ 3. If attending physician is responsible for referring injured employee to another physician, clinic, or hospital, please indicate to which doctor, clinic, or hospital and provide the address thereof. Please give a brief explanation of your referral. _____________________________________ Printed Name of Attending Physician ___________________________________ Signature of Attending Physician _________________________________________________________________________________________ Number, Street and Suite # _________________________________________________________________________________________ City/State/Zip Date of this Report: ______________________ This form must accompany Form 044 _______________________________ Official Form 043 State of Utah * Labor Commission * Division of Industrial Accidents Revised 10/14 160 East 300 South* P.O. Box 146610 * Salt Lake City, UT 84114-6610 * Telephone: (801) 530-6800 Fax: (801) 530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com