39-71-1036. Medical status form. (1) The department shall create a medical status form to be provided to a health care provider providing treatment for a compensable injury or occupational disease.

(2) The form must contain, at a minimum, the following information:

(a) the worker's first and last names and claim number;

(b) the affected body part that is directly related to the compensable injury or occupational disease;

(c) the timeframe during which the treating physician recommends that the worker be completely off work;

(d) the date or anticipated date of the worker's release to modified duty;

(e) the date or anticipated date of the worker's release to full duty;

(f) any temporary work restrictions applicable to the worker;

(g) any permanent work restrictions applicable to the worker; and

(h) the date of the worker's next appointment.

(3) An insurer may request additional information from the health care provider not contained in the department's form.

(4) The treating physician or a designee shall complete the form following every office visit with the worker.