Get Activity Prescription Form

The Activity Prescription Form is a crucial document used to communicate a worker's capacity and restrictions after an injury. This guide will provide you with step-by-step instructions on how to fill out the form online, ensuring clear and accurate information submission.

Follow the steps to complete the Activity Prescription Form online effectively.

1. Press the ‘Get Form’ button to obtain the Activity Prescription Form and open it in your browser or preferred editor.
2. Enter the worker’s name in the designated field. Ensure that the name matches the identification used in official records.
3. Input the visit date to reflect the date when the assessment was made. Use the MM/DD/YYYY format to maintain consistency.
4. Fill in the claim number associated with the worker's insurance case. This helps in tracking the claim efficiently.
5. Print the name of the health-care provider completing the form in the provided field.
6. Record the date of injury. This should also follow the MM/DD/YYYY format as previously noted.
7. Indicate the diagnosis clearly, ensuring that it is accurate and relevant to the injury.
8. Specify if the worker is released to the job of injury without restrictions as of a particular date. If applicable, record the date in the designated field.
9. Provide any key objective finding(s) that support the recommended activity levels for the worker.
10. Indicate whether the worker is able to perform modified duty and fill in the range of dates during which this applies.
11. If applicable, specify any limited hours the worker may be able to work per day and the period these hours apply.
12. Estimate the worker’s capacities in the provided section, noting any restrictions or instructions that need to be followed.
13. Fill out the employer notification section to confirm if the employer has been informed of the worker's capacities.
14. Review all sections to confirm that the information is complete and accurate before saving changes.
15. Once completed, you can save your changes, download the form for your records, or print it out for submission.

Complete your Activity Prescription Form online today for a streamlined process.