Fill and Sign the Physicians Affidavit of Recovery Padepartment of Labor Form

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION physician’s affidavit    of recovery    First name Last name Date of birth Address Address City/Town State ZIP County Telephone Name Address Address City/Town State ZIP County Telephone FEIN EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER - - - - MM DD YYYY eMpLoyee eMpLoyer This is to certify that the aforementioned employee has fully recovered from the following work injury: which occurred on the date shown above, and is able to resume, without limitation, his/her previous occupation of on . - - MM DD YYYY This af�davit is based upon an examination of aforementioned employee performed by the undersigned physician on . - - MM DD YYYY I attest or af�rm that the statements contained herein are true and correct to the best of my knowledge, information and belief. physician SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS DAY OF , First name Last name Signature MM - DD - YYYY Any individual �ling misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud). employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *497*  Auxiliary aids and services are available upon request to individuals with disabilities.    Equal Opportunity Employer/Program    LIBC-497 REV 09-13