Page 207 - Personnel Policy and Procedures Manual

Form RM-WCMT
AUGUSTA, GEORGIA BOARD OF COMMISSIONERS
RISK MANAGEMENT DEPARTMENT
ROOM 217, MUNICIPAL BUILDING (11)
AUGUSTA, GEORGIA 30911
(706) 821-2302 (706) 821-2486

ORDER FOR WORKERS' COMPENSATION MEDICAL TREATMENT

Please render the necessary Medical and Surgical Treatment to care for the injury of -

EMPLOYEE SOCIAL SECURITY # - ____________________

DEPARTMENT - DATE OF INJURY - _____________________

TYPE OF INJURY -

PHYSICIAN'S STATEMENT -

DATE & TIME OF EXAMINATION -

DIAGNOSIS -

TREATMENT -

MEDICATIONS -
REFERRAL -

I, , M.D., have examined/treated the above named employee and in my medical
opinion he/she is -

(1) able to return to work (A) without restrictions or (B) with the following restrictions -

(2) will not be able to work for days weeks.

His or her next office appointment is on

NOTE TO PHYSICIAN - This form must be completed and given to the employee for return to his department.
In the event that the employee is unable to return the form, please mail it immediately to the RISK
MANAGEMENT DEPARTMENT.

Please forward all Workers' Compensation reports and bills to the above address.

Form RM-PAR-SRCDA
WHITE COPY - Risk Management YELLOW COPY - Department PINK COPY - Physician

All Rights Reserved – As approved by the Commission on 05-07-2019 206 | P a g e