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Fill and Sign the Do I Have to Sign a Medical Records Release Form in My

Fill and Sign the Do I Have to Sign a Medical Records Release Form in My

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Form 110 RELEASE TO RETURN TO WORK PLEASE PRINT OR TYPE Instructions: This form must be completed by the adjuster after receiving a physician notification of release to return to full or light duty work. The form must be submitted to the Labor Commission and to the in jured worker within five (5) days of the release date. General Information Worker Name Address Phone Number SS# Injury Date Employer Actual # of Lost Work Days Released to Regular Duty Date Released to Light Duty Date Permanent Impairments, if any: Permanent Impairments, if any: Anticipated Date of Release to Regular Duty: Name of Person Submitting Form Carrier Name Phone Number Date Submitted Official Form 110 Revised 05/16 State of Utah * Labor Commission * Division of Indu strial Accidents 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

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