(Keyboarding, Writing, ☐ ☐ Frequent Frequent Etc.) ☐ ☐ Occasional Occasional Rare ☐ Rare ☐ ☐ ☐ None None Additional Information: Expected Date Of Return To Duration Of Full Duties Restrictions Medical Professionals Medical Professional’s Signature Phone Number Please fax this completed form to SafCom Employee Claims Department at (phone number) and provide a completed copy to your patient to return to the workplace.
(Keyboarding, Writing, Etc.) Frequent ☐ Frequent ☐ Occasional ☐ Occasional ☐ Rare ☐ Rare ☐ None ☐ None ☐ Additional Information: Expected Date Of Return To Full Duties Duration Of Restrictions Medical Professionals Signature Medical Professional’s Phone Number Please fax this completed form to SafCom Employee Claims Department at (phone number) and provide a completed copy to your patient to return to the workplace.
Physician_WDP_Package.docx