Under section 28-33-8(c) of the Rhode Island Workers' Compensation Act, the treating physician files a sworn affidavit with the Workers' Compensation Court's Medical Advisory Board at set points in a worker's incapacity, marked as 10, 20, 30 days or another interval. It reports ongoing treatment, the expected discharge date, whether the employee can return to the former job or other work, restrictions, and maximum medical improvement.
The treating physician completes items 1 to 5, signs with a license number, and swears to the affidavit before a notary public. Employee, employer, insurer and injury details are entered at the top.
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Affidavit of Physician per Section 28-33-8(c) of the Rhode Island Workers' Compensation Act
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The form has checkboxes for ten, twenty and thirty days, plus an 'other' option, matching the points in the employee's incapacity when section 28-33-8(c) calls for the physician's sworn statement. The incapacity date and injury date are entered on the form, and timely filing is tied to the fee in section 28-33-8(b).
Yes. The physician's signature is subscribed and sworn before a notary public, who signs and records the commission expiration date. The footer requires that the original filed with the Medical Advisory Board be signed and notarized, while copies go to the insurer, the physician's file and the employee.