The physician must complete this standard form at every visit, when the injured worker has been placed under work restrictions
or when the injured worker is temporarily totally disabled. The MEDCO-14 also may be used to extend compensation. The
two-part form allows injured workers to receive a copy for their records. Fax a copy to the appropriate managed care organization (MCO), so employers
will know their injured workers’ restrictions and explore work site adaptations/modifications.
Information about who the form was faxed to and where the fax was sent;
Space for the physician’s name stamp;
Easy check-off boxes regarding the work/non-work limitations, physician instructions, whether the injured worker is
temporarily totally disabled, a request for vocational rehabilitation services, and the date and time of his or her
next appointment.
This form reduces the need for phone calls among the parties to the claim regarding the injured worker’s return-to-work
progress, and provides important information to injured workers regarding their recovery and work limitations. Injured
workers have immediate information that they can share with their supervisors when they return to the job. In addition,
employers will see the progress of their injured workers from the beginning of treatment until they are back on the job, and
they will be able to assist in successful return-to-work practices.
