Medical Referral and Work Release Form
Patient's Name_______________________________________________________
Patient's Complaint ___________________________________________________
Patient's Job Duties _________________________ Date of Injury/Illness ________
Referred By: ______________________________________________________
Substance Abuse Screening Policy Testing Consent Agreement & Medical Authorization
Company substance abuse policy requires post-accident substance testing when an injury/illness becomes OSHA recordable or medical treatment other than first-aid is required.
By my signature below, I hereby certify and agree as a condition of my employment and continued employment that:
- I have personally read (or had read to me), understand and will comply with all provisions set forth in the Substance Abuse Screening Policy as presented to me, including this consent to be tested.
- I understand that failure to comply with and/or honor of the terms of this policy is sufficient cause for termination of my employment.
- A photocopy of this consent form will serve in it's stead as an original authorization document regardless of the date signed.
By my signature below, I hereby consent to, and by this Authorization, or any photocopy hereof, authorize the release to my employer or any other agent or employee of the company by any hospital, medical clinic, surgeon, physician, pharmacist or any other provider of medical services, treatment or supplies all medical reports, histories, findings, prognosis, bills, information and other documents relating to any medical treatment, hospitalization, prescription drugs or other medical service or supplies, including psychiatric treatment or treatment for alcoholism or drug abuse provided to or utilized by myself.
Employee Signature _______________________________ Date ____________
Reader/Interpreter Signature _______________________________ Date ______________
______________________________________________________________
Medical Provider: please provide the following information
Please Call {INSERT JOB TITLE} at XXX-XXXX, Extension XXXX
if you need further information or need to relay information concerning this patient.
Date _______________ Time In _______________ Time Out _____________
Diagnosis _____________________________________________________________
Treatment Plan ________________________________________________________
Return Appointment? q Yes q No Date ___________ Time __________ am/pm
Referred to: Dr. __________________ Date ___________ Time ___________am/pm
Continued on reverse side F
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Work Release
Modified work, other than the patient's regular job may be available. To assist in restoring the patient's regular work and pay, please complete the information below
q No Duty from ______________ to _______________
q Modified Duty from ______________ to _______________
q Return to Full Duty on ___________
Modified Duty Limitations Physical Limitations
q No prolonged standing ___________________________________________
q No prolonged walking ____________________________________________
q No prolonged sitting ______________________________________________
q No knee bending, squatting, kneeling _______________________________
q Limited or no use of ______________________________________________
q Weight lifting restrictions __________________________________________
q Keep affected area elevated _______________________________________
q Keep dressing dry and clean _______________________________________
q Use crutches/sling/splint ___________________________________________
q Other _________________ ________________________________________
List of prescribed medication and frequency of directed use
_____________________________________________________________________ Prescribed therapy and frequency
_____________________________________________________________________
Physician Comments:
_____________________________________________________________________________
Physician's Signature _______________________________________________
By my signature, I have read, or had read to me, and fully understand the work restrictions as listed by the Physician.
Patient's Signature ____________________________ Date ____________
Reader/Interpreter Signature _________________________ Date ______________