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RE OF HEALTH CARE INFORMATION Name Address Telephone City State Zip Code PHYSICIAN OR PRACTITIONER: STATEMENT OF PHYSICIAN OR PRACTITIONER Date on which patient can return to work: / / Is the patient able to work his/her normal work schedule? Yes No If not, please identify the number of hours per day and number of hours per week that the patient can work, and the expected duration of the period for the reduced schedule: Describe any restrictions that may apply to the patient s wor.

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