Administrative — Return to Work Letter Template
The Return to Work Letter Template is designed for physicians and healthcare providers completing documentation to clear employees to return to work after illness or injury. This template provides the structured format required by employers to evaluate fitness for duty and includes sections for patient demographics and employment information, medical diagnosis and current status, work restrictions or accommodations if needed, full clearance determination, expected duration of restrictions, and provider attestation. This template streamlines the return-to-work documentation process, ensures clear communication with employers, supports appropriate workplace accommodations, and protects provider time by standardizing documentation. The structured format is adaptable for various medical conditions and return-to-work scenarios. Ideal for primary care practices, occupational medicine practices, and practices frequently completing return-to-work documentation.
Template
Letter Header
Provider name, credentials, practice name
Address, phone, fax, NPI
Date
Patient Information
Patient name, DOB
Employer: [If known]
Job title: [If known]
Medical Status
Diagnosis: [Primary diagnosis]
Current status: [Recovery status]
Treatment: [Current treatment if ongoing]
Return to Work Determination
☐ Cleared to return to work without restrictions
☐ Cleared to return with restrictions: [Specify restrictions]
☐ Cleared to return with accommodations: [Specify accommodations]
☐ Not cleared to return: [Reason and expected clearance date]
Work Restrictions (If Applicable)
Physical restrictions: [Lifting, standing, etc.]
Activity restrictions: [Specific limitations]
Duration of restrictions: [Expected duration]
Reassessment date: [If applicable]
Provider Attestation
I certify that the above information is accurate and that this patient is [cleared / not cleared] to return to work as specified above.
Provider Signature
[Signature, credentials, date]
💡 Tip: Click anywhere to edit. Changes are temporary.
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