MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
BI-WEEKLY REPORT ON PHYSICAL REHABILITATION
Injury Number: Employee: Employer's or Insurer's No: Selected Facility:
The employee in the Missouri Workers' Compensation case captioned above has been receiving physical rehabilitation in the facility named for the two week period shown below: (Please fill in dates.) List dates employee reported for treatment during the two week period:
List dates of cancellations/no shows, if any, during the two week period:
If employee completed the rehabilitation program during this period, please give the last date attended prior to discharge:
Authorized Signature
Title
Phone Number
Please return form to: Fax: 573-522-1623 Phone: 573-526-3876 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-5A (07-03) AI