Fill and Sign the Fillable Online Form 3 Arkansas Workers Compensation pdfFiller

Form AR- 3A Carrier, Self Insured Employer, or Third Party Administrator may print its name and address here. 3 Authority: Ark Code Ann. §11-9-516 and AWCC Rule 27 Revised 1-1-2001 PHYSICIAN’S REPORT “ First Report“ Progress Report“ Final Report Date of Release From Treatment AWCC File No.Carrier Claim No.Claimant Name (Last, First, MI)Claimant SS No. Employer NameEmployer Address CityStateZip Code Carrier Or Self-Insured NameMailing Address Physician’s Report of Injury and Treatment Brief Description of Accident Diagnosis/Treatment Rendered Prognosis/Expected Duration of Treatment If claimant is suffering from any other disabling condition not due to this accident, specify condition: NOTE TO COMPLETING PHYSICIAN: THE BACK SIDE OF THIS FORM MUST ALSO BE COMPLETED, WHERE APPLICABLE. 3 Temporary Disability3The claimant cannot return to work due to his/her work-related injury until after his/her next appointment with me on (date). The claimant cannot return to work due to his/her work-related injury until (date). The claimant can return to work on (date) with no restrictions. The claimant can return to work on (date) with the following temporary restrictions: “No standing for more than hours “No sitting for more than hours “No lifting more than pounds “No working more than hours per day “Other (specify):Permanent Disability“The claimant has suffered no permanent impairment due to his/her work-related injury. “The maximum medical improvement date (end of healing period): (date) “The claimant has suffered a permanent impairment rating of % to the body as a whole, based on objective and measurable findings such as: “The claimant has suffered a permanent impairment rating of % to the (body part). “ The claimant has suffered facial or head disfigurement. “ The claimant has suffered permanent, total disability.Physician InformationLicense StateDate of AR LicensureLicense Number Physician’s SignaturePhysician’s Printed or Typewritten NameDate Form 3 is approved by the Arkansas Workers’ Compensation Commission, P.O. Box 950, Little Rock, Arkansas 72203-0950, for use by providers to report the status of a patient’s treatment. Form 3 should be sent by the medical provider to the company handling the workers’ compensation case for the employer.