STATE OF SOUTH CAROLINA	)	IN THE FAMILY COURT
)	JUDICIAL CIRCUIT
COUNTY OF	)
)
)
Plaintiff,	)	PHYSICIAN’S REPORT
)
vs.	)
)
)
Defendant.	)	Docket No.

The undersigned: (Print Name Here)

Doctor Nurse Nurse Practitioner Physician’s Assistant Other

Affirms that:

1. Patient’s Name: DOB SSN (last 4 digits)

2. The patient is being treated for (basic diagnosis): .

3. Date treatment began for this particular injury/disabling condition: .

4. Patient is	able to work in his/her usual occupation.

not able to work in his/her usual occupation.

can work in a limited capacity as described below in Item 8.

released from care.

not now and has never been our patient.

5. Patient is	permanently and totally disabled.	temporarily disabled.

partially and permanently disabled.	partially and temporarily disabled.

other:

6. Present prognosis is that patient will be released to return to work on (date)

7. Patient is scheduled to be seen again on and/or has surgery or other treatment scheduled for for .

8. Comments:

Signed: ___________________________________________Date:________________________

Address:

Phone:

This document is HIPAA compliant by consent of the individual named above.

SCCA 456 (12/2009)

SCJD

2009-12-14

wclark