Form Dwc 27 28 PDF Details

When an employee is ready to return to work after sustaining an injury, the DWC 27 28 form plays a pivotal role in the transition process. This form, known as the Physician’s Notice of Release to Work, requires submission to the insurer within three days of the employee being cleared to resume employment, ensuring all parties involved— the employee, their attorney, and the insurer—are well-informed. It carries critical information including the employee and employer details, along with the specifics of the injury and the physician’s assessment regarding the employee's capability to return to work, which may indicate whether the return is to regular duty without restrictions or to modified duty with certain limitations. These limitations could range from restricted heavy lifting to prohibitions on repetitive physical activities, tailored to the employee's medical condition and recovery progress. Additionally, the form serves as a certification that the employee does not require further medical items or services related to the injury. This document, mandated by Section 28-33-8(b) of the RI Workers’ Compensation Act, not only facilitates the smooth reintroduction of an employee into the workplace but also upholds their rights to a safe and adjusted work environment, if necessary. Through this form, the Division of Workers’ Compensation enforces a structured approach to handling work-related injuries, ensuring clarity and protection for all parties engaged in the workers’ compensation system.

QuestionAnswer
Form NameForm Dwc 27 28
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSupervising, repetitive, stooping, release to work form

Form Preview Example

PHYSICIAN’S NOTICE OF RELEASE TO WORK

Submit to insurer within three (3) days of release to work with a copy to the employee and his or her attorney.

DWC/MAB File #

 

Insurer’s File #

 

Employee/Patient Information:

Employer Information:

Social Security #

 

FEIN #

 

Name

 

Name

 

Address

 

Address

 

City, State, Zip

 

City, State, Zip

 

Phone

 

Phone

 

Date of Birth

 

 

 

Injury Date:

 

 

 

Insurance Carrier:

 

Adjusting Company:

Name

 

Name

 

Address

 

Address

 

City, State, Zip

 

City, State, Zip

 

Phone

 

Phone

 

If the insurer is not known, contact the Division of Workers’ Compensation at (401) 462-8100.

Section 28-33-8(b) of the RI Workers’ Compensation Act provides for a $20.00 fee to be charged for the

timely filing of this form.

This medical report is rendered pursuant to Section 28-33-8 of the RI Workers’ Compensation Act. This is to certify that the above named employee is able to return to work on

To (check one)

 

Regular duty, no restrictions

 

Modified duty, limitations as follow:

Indicate modified duty restrictions:

 

 

 

 

No operating heavy machinery or vehicles

 

 

 

Alternate standing/sitting

 

 

 

 

 

 

 

 

 

 

 

 

No repetitive climbing ladders or stairs

 

 

 

No work involving use of right/left ___________

 

 

 

 

 

 

May lift up to ________ pounds only

 

 

Sit down work only

 

 

 

 

 

 

No reaching above shoulders

 

 

Keep wound clean and dry

 

 

 

 

 

 

No repetitive twisting, bending, squatting

 

 

Other _________________________________

 

 

No repetitive stooping, kneeling

_____________________________________

 

 

The patient will require no further medical items or medical services associated with this claim.

This certification is based on the medical examination performed on

Physician’s signatureDate

Physician’s name

Treatment facility

Physician’s Assistant Signature

Supervising Physician’s Name

Physician’s Address

Form DWC-27/28 (7/09) RI Department of Labor & Training, Division of Workers’ Compensation

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Part # 1 of filling out squatting

2. The third stage would be to fill in the following fields: Indicate modified duty restrictions, No operating heavy machinery or, No work involving use of, May lift up to pounds only, Sit down work only, No reaching above shoulders, Keep wound clean and dry, No repetitive twisting bending, Other, No repetitive stooping kneeling, The patient will require no, This certification is based on the, Date, Physicians signature, and Physicians name.

How you can prepare squatting stage 2

Be really mindful when completing This certification is based on the and No repetitive twisting bending, as this is the part in which most people make errors.

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