Get NM Return to Work
________ Diagnosis: _______________________________________________________________________ ONE OF THE FOLLOWING THREE BOXES MUST BE COMPLETED ON RETURN TO WORK STATUS: Return to work full duty with no restrictions on this date:_________________________ (form completed please sign below) Unable to return to work until next evaluation on this date:________________________ (form completed please sign below) Able to return to work with the restrictions MARKED IN THE BOXES BELOW Functional Limitati.
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