Pennsylvania employers and insurers seeking to end workers' compensation benefits may ask the examining physician to sign this affidavit. The physician certifies that the employee has fully recovered from a described work injury and can resume the previous occupation without limitation as of a stated date, based on an examination. The sworn statement is then used in proceedings before a workers' compensation judge.
The examining physician completes the whole affidavit, signs it, and swears or affirms it before a notary, who completes the jurat. Employee and employer identification fields appear at the top.
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Physician's Affidavit of Recovery
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No. The affidavit certifies that the employee has fully recovered and can resume the previous occupation without limitation. If the examination shows remaining limitations, the form has no place to record them, since it offers only the full-recovery statement, the recovery date and the examination date.
Yes. The physician signs the attestation and the notary completes the 'subscribed and sworn to (or affirmed) before me' section with the date, name and signature. The affidavit is a sworn statement for use before a workers' compensation judge, so the notarized original matters.