Employer’s Modified Duty Report Form
Form Template
A Health Care Provider/Physician MUST complete his/her portion of the Employer’s Modified Duty Report Form mobile app, sign and return to employer within fourteen (14) days of the next date of service after the Health Care Provider /Physician's receipt of the app from the employer, but not later than twenty-one (21) days from the Health Care Provider/Physician's receipt of the app.
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The app documents Employee and Employer Information, Job Description’s, Classification of Work, Work Postures/Positional Requirements and Work Frequency.
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