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Fill and Sign the Physician Authorization of Supplemental Disability Oregon Form

Fill and Sign the Physician Authorization of Supplemental Disability Oregon Form

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PHYSICIAN AUTHORIZATION OF SUPPLEMENTAL DISABILITY Worker: You are responsible for getting this form completed by your physician to continue receiving supplemental disability.W orker             Worker name Date of birth                   Date of injury Claim number Primary insurer Definitions:  Primary job means the job at which the injury occurred.  Secondary job means any other job held by the worker at the time of injury.  Temporary disability means wage loss replacement for the primary job.  Supplemental disability means wage loss replacement for the secondary job(s) that exceeds the temporary disability. Physician             Physician’s name (printed) Phone number                         Address City State ZIP Medically stationary? Yes (date):       No (anticipated date):       Worker/patient ability to work: Regular work authorized start (date):       Modified work authorized from (date):       through (date, if known):       No work authorized from (date):       through (date, if known):       Restrictions:       I certify that these restrictions apply to : Primary job Secondary job       Physician’s signature Date 440-3531 (9/03/DCBS/WCD/WEB)

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