Free Referral for Specialist Medical Opinion Template – Download Now
A Referral for Specialist Medical Opinion Regarding Work Capacity is used when an employer or doctor needs a specialist’s evaluation to determine whether an employee can safely perform their job duties.
Why Use This Referral Form?
This form is essential when:
- An employee has suffered a workplace injury and needs a work capacity assessment.
- A worker is returning after a long illness and may require job modifications.
- An employee requests accommodations due to a medical condition.
- A job transfer involves new physical demands that require medical clearance.
Who Initiates the Referral?
- Employers concerned about an employee’s ability to perform job duties.
- Primary care physicians or treating doctors who need a specialist’s opinion.
What Does the Specialist Do?
- Conducts a comprehensive medical evaluation of the employee.
- Reviews medical history and performs physical examinations.
- Assesses the employee’s functional work capacity.
- Provides a detailed report with recommendations, including:
-
- Whether the employee is fit to return to work.
- If job modifications are necessary.
- Whether work restrictions should be applied.
Template Categories
California
General
How to Use the Templates
- Tap to download the Specialist Medical Opinion Referral form for free from this page and type in your email ID.
- Download the form from your inbox.
- Fill in your details, including your name, medical license number, and exam date selection.
- Submit the completed form to the DWC Medical Unit as instructed on the form.
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