Return to Work Form

6/22/2023

Disability Management Office (DMO)

State of Michigan

Phone: 877-443-6362, option 2

MEDICAL RELEASE TO RETURN TO WORK

To be

completed by employee:

Patient/Employee name: Employee ID#: Date of birth:

The below information is required for our employee to return to work from a medical

leave, maternity leave or paid parental leave (birthing mothers only).

This statement must be received 5 days before the leave end date and must be

signed and dated by the physician within 14 days of return date.

To be completed by health care provider:

Patient may return to work with NO restrictions on:

(provide date)

Patient may return to work WITH restrictions on: (provide date)

Patient’s restriction will end on: (provide date)

DETAILS OF RESTRICTIONS:

alth care provider name and business address:

Name:

Address:

Type of practice/medical specialty:

Phone number:

Fax number:

Signature of health care provider:

Date:

Return completed form to:

Fax: 517-284-9951