Get Activity Prescription Form

Completing the Activity Prescription Form online is an essential step in documenting a worker's injury status and capabilities. This guide provides clear, step-by-step instructions to help healthcare providers fill out the form accurately and efficiently.

Follow the steps to complete the Activity Prescription Form online.

1. Press the ‘Get Form’ button to access the Activity Prescription Form and open it in your preferred document editor.
2. Begin by filling in the worker’s name at the top of the form. This identifies the individual for whom the prescription is being issued.
3. Enter the visit date, which is the date you are completing the form. This helps to maintain accurate records.
4. Input the claim number associated with the worker's injury. This is critical for processing any related claims.
5. Provide the healthcare provider’s name in printed format. This ensures clarity regarding who is issuing the prescription.
6. Record the date of injury, which is vital for tracking the timeline and history of the worker's situation.
7. Document the diagnosis. A clear diagnosis is essential for understanding the worker's condition and guiding their treatment.
8. Indicate if the worker is released to the job of injury without restrictions and note the date if applicable. If they are not fully released, proceed to further details.
9. Fill in the required key objective findings and additional information regarding the capacity to perform work-related tasks. This information is crucial for assessing the worker's abilities.
10. If the worker may perform modified duty, specify the dates and check the relevant options based on their capabilities and limitations.
11. Ensure that any notes regarding current rehabilitation, ongoing treatment, or past surgeries are accurately filled out.
12. Before finalizing the form, review the sections on employer notification and modified duty availability.
13. Sign and date the form in the required signature area to validate the documentation.
14. Save any changes made to the form. You can then choose to download, print, or share the completed Activity Prescription Form with the necessary parties.

Complete the Activity Prescription Form online today to ensure proper documentation and care for injured workers.