Physician's Return to Work Release form

Physician's Return to Work Release form

MAA

Physi cian’s Return to Work Release

Benefits Department

6815 Poplar Avenue, Suite 500  Germantown, TN 38138  (901) 682-6600

TO BE COMPLETED BY THE ASSOCIATE

Name: ___________________________________________

I ____authorize _____ do not authorize (check one) the Health Care Provider (HCP) identified below to provide the information requested on this form for the purposes of determining my fitness for duty and for a designated MAA human resources professional to contact the HCP to authenticate and/or clarify the information if needed. I understand that my return to work date may be delayed so that my employer can evaluate any identified restrictions. If restrictions are substantially limiting, are expected to continue longer than 3 months or are considered permanent, you must contact the Benefits department to begin the Americans with Disabilities Act as amended (ADAAA) process to determine if a reasonable accommodation can be provided.

_______________________________________________

_________________

Associate ’s Signature

Date

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ TO BE COMPLETED BY THE HEALTH CARE PROVIDER

(1) This condition is: (2) Employee may:

Not work related.

Work related.

Return to work on Return to work on

(date) without restrictions.

(date) with restrictions as indicated below through

(date).

Unable to return to work from (date) due to incapacity or restrictions. Restrictions listed below are PERMANENT ________ or TEMPORARY _____(check). If temporary, the expected duration:___________ (date) to

(3) Employee may work full-time hours?

YES

NO

If NO : Maximum hours/workday:

Maximum hours/week: _______

(4) Work Restrictions

NONE 0%

OCCASIONALLY 0-3 Hrs

FREQUENTLY 4-6 Hrs

CONSTANTLY 7-8 Hrs

Associatemay perform activity : (check)

Lifting/Carrying maximum ___ pounds Pushing / Pulling maximum pounds Fine Manipulations Reaching above shoulder R / L (circle) Grasping / Squeezing Keyboarding Repetitive hand / wrist motion R / L (circle)

Crawling Twisting Sitting

Standing / Walking Squatting / Kneeling Repetitive bending / stooping Climbing stairs Climbing ladders Drive vehicle for work purposes

Other Restrictions (if any):

Health Care Provider Signature: ____________________________________________________ Date: __________________________

Health Care Provider Printed Name: ____________________________________________

Address: __________________________________________________________ Phone: _____________________ Fax: ______________________

To speak to a Manager, please call (

) ___________________. Ask for _____________________________________________.

General Information : This form helps gather return to work information and will help us determine if a suitable temporary modified job/duty is available for the associate to perform while he/she recovers.

GINA Safe Harbor Statement : The Genetic Information Nondiscrimination Act (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request. 'Genetic information,' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual 's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Rev 06 3.7A.F4

09/19/17 Tracy Wilkins