Request For Summary Rating Determination of
Primary Treating Physician Report form
Valid Values:
'EMPLOYEE' - for Employee
'CLAIMS ADMINISTRATOR' - for Claims Administrator
Claims Administrator Information (if known and if applicable)
Please leave blank spaces between numbers, names or words
Please leave blank spaces between numbers, names or words
Employee Information Section.
Valid Values (not case sensitive):
'Mr.' 'Ms.' 'Mrs.'
Please leave blank spaces between numbers,
names or words
DESCRIBE THE GENERAL DUTIES OF THE JOB (Attach job description
or job analysis, if available)
An S signature is required. An S signature consists of the letter
"S" followed by the name of the person signing the document, in the following
format:
S JOHN JONES. Do not enter a middle name or initial.