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)
Is this employee temporarily totally disabled?
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