Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to obtain the document and open it in the appropriate online editor.
2. In Section A, enter the patient information. Fill in the employee's last and first name, the date of injury in the format mm/dd/yyyy, and the employee ID number. Additionally, input the supervisor's name and phone number, followed by the supervisor's signature and date.
3. Direct the employee to authorized treatment facilities for initial care, specifically those located in Wake County, as outlined in the form.
4. Section B requires the medical provider to document the diagnosis, treatment given, and any medications prescribed. Ensure all details are accurate and complete.
5. In Section C, the medical provider must indicate the work status of the patient. Specify whether the patient can return to work without restrictions, with restrictions, or if they cannot return, along with the respective dates.
6. Complete Section D by detailing any work restrictions applicable to the patient, including posture, movement limitations, and maximum hours allowed per day.
7. In Section E, document any follow-up appointments, including the date and time, ensuring that it is communicated to the relevant parties for approval.
8. Finally, the medical provider must sign, print their name, and date the form. After completing all sections, save changes, and ensure to download, print, or share the form as needed.

Complete your documents online now to ensure proper and timely medical treatment authorization.