Free Physician's Rehabilitation Information Sheet (WCR-1A) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

PHYSICIAN'S REHABILITATION INFORMATION SHEET
The purpose of this form is to gather additional information to determine eligibility for physical rehabilitation benefits for the indicated injured employee. Please note the date of injury and complete the form according to the patient's condition at the time of the injury or initiation of rehabilitation. (The condition at the time of injury and rehabilitation may be different from present condition). Employee: Employer: Injury No: Insurer's No:

Attending Physician: Complete Mailing Address: Phone Number:

Rehabilitation has been received: Rehabilitation is currently being received: Rehabilitation is expected to be received: No rehabilitation received or indicated:

Yes Yes Yes Yes

No No No No

Insurance contact person for this claim: Name: Phone Number:

Return completed form to: Fax: 573-522-1623 Mail: Attn: Rhonda Forck Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, Missouri 65102-0058

Relay Missouri: 1-800-735-2966 (TDD) 1-800-735-2466 (Voice) www.dolir.mo.gov/wc

WCR-1A (07-03) AI