Appendix T

LETTER TO HEALTH CARE PROVIDER ABOUT RETURN-TO-WORK

Dear   _______________________:
 
(Name of Company) is committed to returning injured or ill employees to work within their capabilities. We believe that an employee who returns to work as soon as medically appropriate, and within his or her work restrictions, regains economic security, physical strength and flexibility, and has improved psychological well-being.
 
I am writing to ask for your opinion concerning Mr./Ms. ______________’s ability to return to work at this time. Enclosed is an analysis of Mr./Ms._______________’s regular job (and/or proposed Transitional Employment Plan). Based on your review of the enclosed Return-to-Work Program (and/or proposed transitional employment plan) and your examination of Mr./Ms. ________________, please choose one or more of the following:
 
I release the employee to the job as described in the Return-to-Work Program (or proposed Transitional Employment Plan) effective _____________.
 
I release the employee to the activities as described under the following conditions:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
 
I cannot release the employee to any part of the duties described at this time.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
 
An appointment to review the employee’s condition further is scheduled for_________________.
 
Provider’s Name_________________________          Date_____________________
 
Please feel free to provide any additional comments you have concerning Mr./Ms.___________’s ability to work.
 
Thank you for your assistance with this matter.
 
 
Sincerely,
 
 
Enclosure (Your Company name) Return-to-Work Program Details (and/or other attachments)
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