Free Form 4A - Oklahoma



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FORM 4A SEND COPIES TO: 1- Employee/Claimant 1 - All Other Parties of Record In re claim of: Full Name of Employee (Claimant) Employee's Social Security Number WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918 THIS SPACE FOR COURT USE ONLY TREATING PHYSICIAN'S PROGRESS REPORT Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured FILE NO. Date of Injury (Please type or print) DATE PROGRESS REPORT: Is this employee temporarily totally disabled? NO YES I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HE

FORM 4A SEND COPIES TO:
1- Employee/Claimant 1 - All Other Parties of Record In re claim of:
Full Name of Employee (Claimant) Employee's Social Security Number

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918

THIS SPACE FOR COURT USE ONLY

TREATING PHYSICIAN'S PROGRESS REPORT
Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured FILE NO. Date of Injury

(Please type or print)

DATE

PROGRESS REPORT:

Is this employee temporarily totally disabled?

NO

YES

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.

I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee/Counsel Address (Number & Street) Signature of Physician City State Zip Code Address (Number & Street) City State Zip Code

Employer/Counsel Address (Number & Street) City State Zip Code

Telephone Number of Treating Physician Print or type name of Treating Physician

2/06

File Size: 34.6 kB
Pages: 1
Date: February 13, 2006
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: BCDelozier
Word Count: 182 Words, 1,182 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.owcc.state.ok.us/CourtForms/Current/Form%204A.pdf