Fill and Sign the California Treating Form

                                   I expect to release the employee to return to the pre-injury occupation on or about       Yes No If yes, please describe any physical limitations:                   At this time, I am unable to give an opinion concerning the employee's ability to return to the pre-injury occupation. I expect to be able to provide an opinion on or about:       Yes, with the following limitations- No                                                                                           TREATING PHYSICIAN'S REPORT OF DISABILITY STATUS INSTRUCTIONS: Pursuant to requirements of the California Labor Code, please complete this form and return it to the claims administrator listed below within 15 days of receipt with a copy to the Qualified Rehabilitation Representative. EMPLOYEE NAME: (LAST) (FIRST) (M.I.) SS # DATE OF INJURY EMPLOYER NAME:Attached is a description of the employee's job duties. Based on your examination, including the history provided by the patient and the enclosed job description, choose one of the following: The employee's permanent disability as a result of the injury whether or not combined with the effects of a prior injury or disability, if any, is likely to preclude the employee from returning to work at the pre-injury occupation. Is the employee currently physically able to participate in vocational rehabilitation services? If employee is not physically able to participate in vocational services, please estimate when participation may be possible: Please advise also if the employee is currently physically able to perform light duties if modified or alternative work is available: Physician's Name - Date - Physician's Signature- Please return to: Employer/Insurer/Adjusting Agent Claim #- Address: (Street) (City) (State) (Zip) Send a copy to Qualified Rehabilitation Representative: Address: (Street) (City) (State) (Zip) State of California DWC Form RU-90 (12/90) Rehabilitation Unit California Division of Workers' Compensation Form RU-90 TREATING PHYSICIAN'S REPORT OF DISABILITY STATUS Purpose: To allow early identification of employee's potential need for vocational rehabilitation services, the claims administrator or Qualified Rehabilitation Representative must solicit the treating physician's opinion concerning the employee's ability to return to previous employment. Submitted by: Qualified Rehabilitation Representative assigned by claims administrator, if the injury is before 1/1/94, or claims administra- tor if the injury is on or after 1/1/94. When submitted: At 90 days of aggregate temporary disability and thereafter at 60 day intervals, or less, until medical eligibility has been determined. Where submitted: To the treating physician. Do not file the RU-90 or RU-91 with the Rehabilitation Unit unless specifically requested or when submitting information as part of a dispute. Form completion: The Qualified Rehabilitation Representative or claims administrator completes the identification data on the form and the treating physician is responsible for the completion of the remainder of the form, including signature. Be sure to fill in the claims administrator name and address or the doctor may become confused and return the form to the Rehabilitation Unit. Upon completion, the treating physician returns the form to the claims administrator with a copy to the Qualified Rehabilitation Representative, if applicable, and injured worker. Accompanying document: Description of Employee's Job Duties (RU-91) must be included when the RU-90 is initially sent to the treating physician. Response to RU-90: The claims administrator within I 0 days of receipt of the final Treating Physician's Report Of Disability Status Form RU-90, shall notify the employee of his/her status using the prescribed Notice of Potential Eligibility or Denial of Vocational Reha- bilitation Services, whichever is applicable. The completed RU-90 is a medical report and is to be served on all parties by the claims administrator with the previously completed RU-91. Rehabilitation Unit action: None.