Fill and Sign the Ri Workers Compensation 497325285 Form

MF                                                                            DWC/MAB Number:       Insurer's Number:       FEIN       Name       Address       City, state, zip       Name      Address       City, state, zip       Date of Injury:       other       the employees return to work or a suspension of benefits for other reasons is imminent; the employee is under and following a rehabilitation program approved by the Director of Labor; Other            - - ( ) - / / ( ) - / / 26 week 39 week 52 week WAIVER OF MEDICAL REVIEW (Section 28-33-34.1 of the R.I. Workers' Compensation Act) State of Rhode Island Workers' Compensation Court Medical Advisory Board One Dorrance Plaza Providence, RI. 02903-3973 Phone: 277-3097, TDD: 277-3332 EMPLOYEE INFORMATION: Soc. sec. no.EMPLOYER INFORMATION: Phone Date of birth Phone INJURY INFORMATION- Medical Review Waived (Circle One) The undersigned requests that the medical review of the employee be waived for the following reason. the employee is receiving benefits for total incapacity, and the employees condition is so severe or permanent that examination and review is clearly inappropriate and unnecessary; the employees condition has been previously reviewed by the attending physician, comprehensive independent health cm review team or impartial medical examiner. or in an approved rehabilitation program and was then determined to be and remains stable and at maximum medical improvement, and die employee has had an earnings capacity adjustment appropriate to his or her present level of earnings capacity: or the employee is receiving weekly compensation benefits from a self-insured employer that has filed and received approva l of a request for exemption from the provisions of section 28-33-34.1 of the Rhode Island Workers' Compensation Act. Employer/Carrier (Type or Print) Signature of Authorized Representative Date of Report -