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.

Template webp scaled - LezDo TechMed Templates

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:
    1. Whether the employee is fit to return to work.
    2. If job modifications are necessary.
    3. 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.

Related Templates

Free QME Complaint Form – Download Now

Free QME Complaint Form – Download Now

Free QME Complaint Form – Download NowThe Qualified Medical Evaluator (QME) Complaint Form is a vital document for individuals seeking to file a formal complaint against a Qualified Medical Evaluator (QME) in California. This form allows injured workers, employers, or...

Free QME Form 108 Template for QME Panel Selection

Free QME Form 108 Template for QME Panel Selection

Free QME Form 108 Template for QME Panel SelectionThe QME Form 108, also known as the Qualified Medical Evaluator Panel Selection Instruction Form, is an essential document used in California workers' compensation cases. It provides crystal clear instructions to...

Fill-in to Download the Sample

Free Referral for Specialist Medical Opinion Template

Name(Required)