Note to Injured Worker: Please Provide This Form to Your Treating Medical Provider

Note to Injured Worker: Please provide this form to your treating medical provider

~ REMINDER TO MEDICAL PROVIDER ~ EMPLOYEES ARE OUR MOST VALUABLE ASSET!!

Employee Name: ______SS#: ______

Body Part Injured: ______

Date of Injury: ______

Employer Name: ______Phone #: ______

Authorized Employer Signature: ______

Date: ______

MAIL PROVIDER BILLS WITH PROPER DOCUMENTATION TO:

Eastern Alliance Insurance Group P.O. Box 83777 Lancaster, PA 17608-3777 1-855-533-3444

This form does not guarantee coverage or compensability of workers’ compensation claim. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WE OFFER MODIFIED DUTY!!

It is the policy of our company to aid an employee’s rehabilitation by providing opportunities for returning to work at the earliest time possible. We will work to accommodate this employee’s restrictions and provide them with work within those restrictions while they are in effect.

We will not ask an employee to do any work outside of their medically prescribed restrictions and expect them not to attempt any work that exceeds those restrictions.

If you have any questions regarding our company’s modified duty program, please contact me at the number listed above.

Thank you,

Employer Name and Title ------(Clip and Return)

TO BE COMPLETED BY PHYSICIAN:

______Yes, employee may return to work on modified duty (see restrictions).

______No, employee may NOT return to work (see restrictions).

______Physician’s Signature Date