Free Verification of Rehabilitation Treatment (WCR-4A) - Missouri

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

VERIFICATION OF REHABILITATION TREATMENT
Injury Number: Employee: Date of Injury: Rehabilitation Facility: SSN:

Phone Number: Contact Person: OUTPATIENT TREATMENT Type of rehabilitation received (be specific):

Date rehabilitation began: List all dates client has attended therapy:

# of days per week therapy ordered:

List all dates client cancelled or did not attend scheduled therapy:

Please list date employee returned to work: INPATIENT TREATMENT Type of rehabilitation received (be specific):

Admission Date: Is therapy continuing at present? List all dates client received therapy:

Yes

# of days per week therapy ordered: If "No," list discharge date: No

List all dates client did not receive scheduled therapy:

Please return form to: Fax: 573-522-1623 Phone: 573-526-3876 Mail: Attn: Physical Rehabilitation 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-4A (07-03) AI