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MEDICAL AUTHORIZATION <br />Form AI-2 <br />To: <br />Date: <br />Please render immediate medical treatment to the person named below. <br />Injured/Ill Person Date of Injury/Illness Time of Injury <br />Last Name First Name Month Day Year Hour AM/PM <br />Medical treatment rendered is subject <br />To the provisions of the State Workers' <br />Compensation Act. <br />Date Injury/Illness Reported Employee <br />No. <br />Social <br />Security # Month Day Year <br />Give a brief description of injury/illness. <br />For our information, we request that the following information be completed and this form given to the injured/ill <br />for return to MS. If the person is not return immediately to work, please call <br />The person may return to normal work duties at once. <br />The person is totally incapacitated at this time <br />Person may return to work with the following restrictions: <br />Patient can return to work on (date) <br />Patient can resume regular duties after (date) <br />Patient will be re-evaluated on (date) <br />Date of next treatment <br />I saw the patient on (date) and have made the following diagnosis: <br />Healthcare Providers Signature: Date: <br />Healthcare Providers Name: Title: <br />Address: