Physician Statement /Return to Work - Citgo

CITGO Petroleum CorporationPhysician Statement /Return to WorkTo be completed by EmployeeEMPLOYEE NAME (PRINT LAST, FIRST, MIDDLE) SOCIAL SECURITY NO. DATE LAST WORKEDEMPLOYEE SIGNATUREI hereby authorize my attending physician to release any information or copiesthereof acquired in the course of examination or treatment for the injury/illnessidentified below to my employer or their representatives.DATELOCATIONSUPERVISORTo be completed by attending Physician(please attach additional sheets, if necessary)EMPLOYEE DIAGNOSISDATE OF ONSETFOR THIS ILLNESS, DATE OF FIRST EXAM/TX:Work Related Yes NoDATE OF LATEST EXAM/TX:Current Medical Status:Recovered: may return to work with no limitations onMay return to work with the following restrictions (be specific)*These restrictions are in effect until(date)or until employee reevaluated on (date)Employee remains totally incapacitated at the present time and will be reevaluated onThe expected return to work date:Physician’s comments:RX:PHYSICIAN’S NAME (PLEASE PRINT)PHYSICIAN’S SIGNATUREPHONE NO.DATEADDRESS STREET CITY STATE ZIPReturn CITGO Health Services, P.O. Box 3758, Tulsa, OK 74102 or fax to (918) 495-571021-72-54E (2-99)

CITGO Petroleum CorporationP.O. Box 3758Tulsa, OK 74102-3758Secured Fax: (918) 495-5710Physician Statement / Return to WorkEmployee Instructions:• You are required to provide a completed form following:– absence from work three or more consecutive work days– emergency room visits– hospital admission, regardless of reason– any surgical procedure– medical attention or if taking medication that may affect safety or job performance– occupational injury or illness– returning to or from transitional duty– requirement by management• You are required to provide a completed form:– before actually returning to work activities– within 7-10 business days of start of absence > 3 days– to be updated at least every 30 days or as required by management• You must have a completed form from each treating physician.• “Return to Work” status must be approved by Health Services before returning to work. To alleviate any possibledelays, please submit to Health Services 1-2 days prior to return.• If you choose to fax he completed form, please send the original copy of the form to CITGO Health Services. The fax inHealth Services is in a secured area in order to protect the confidentiality of your personal medical records.• CITGO Health Services will protect the confidentiality of all personal medical information.• After exhausting your Short-Term Disability entitlement, you may have a right to FMLA unpaid leave due to your ownserious health condition.Transitional Duty:• If the treating physician has identified work restrictions, Health Services will collaborate with the facility managementfor approval of accommodation(s).• If the treating physician has identified work restrictions, Health Services will collaborate with the facility managementfor approval of accommodation(s).• Work restrictions must be reviewed every 4 weeks.• Transitional duty will not exceed 6 months duration.Physician Instruction:• To assist the company in evaluating this employee for safe assignment upon return to work, it will be necessary for youto furnish the information requested. Your reply will be considered confidential• If you choose to fax the completed form, please send the original copy of the form to CITGO Health Services, P.O. Box3758, Tulsa, OK 74102-3758.• If you identify work restrictions, please be specific. For example, weight limitations need the maximum weight allowedstated such as “No lifting greater than 25 lbs.Supervisor Instructions:• Forward the original and/or all copies of this form to Health Services.Refer to Short Term Disability – STD Policy, Rev. 12/98