CMC-Lake Forest

22741 Lambert Street Suite 1608 Lake Forest, CA 92630

Phone: +19495813011 Fax: 949.581-6457 Service Date: 03/30/2023
Claim Number: y3WCO5905 Case Date: 08/01/2021

Work Activity Status Report

Patlent: REGINA STAZAK Last 4Dlglts of sSN: XXX-XX-9157 Date of Birth: 09/22/1986

Address: 25 Bearpaw 27A IRVINE CA 92604 Employer Locatlon: MerchSource LLC Contact: Sue Petrovich
Address: 7755 Irvine Center Dr Ste 100 Irvine. CA Role: Primary Contact
Home: +19165714635 92618-2904 Phone: +19496361480
Work: Authorlzed by: Connie Owens Fax: 0-0-0000

THIS VISIT Vislt Type: Recheck Time In: 10:00:00 AM Time Out: 10:51.39 AM
Treating Cllnlclan: Mary Bos, D.O.
Diagnoses: Medicatlons:
Carpal tunnel syndrome of left wrist (G56.02) G Dispensed prescription medication
Dispensed over-the-counter medication
Medication(s) prescribed

PATIENT STATUS
Employer Notice: The prescribed activity recommendations are suggested guldellnes to assist in the patient's treatment and rehablitation. Your employee has been
informed that the activity prescription is expected to be followed at work and away from work.
Treatment Status:

Returning for follow-up: 2 WEEKS

Anticipated MMI Date: 05/2023

Work Status:
No work

Actlvity Prescription:
Key': Occasionally up to 3hrs/day, Frequently up to Ghrs/day; Constantly =up to 8 hours or greater per day
OFF WORK

Basedon the Department of Labor definltons DODOOD

OgZ00D
O000DB
NEXT VISIT(S) Visit Date and Time: Vlslt Typ0: cllnlclan:
Medkal Iherapy Speclallst
Patlent Notice: it is essential to
your recovery that keep your 04/13/2023 10:45 AM Mary A Bos,DO
cheduled appointments hut
should youneed to reschedule or
cancel, please contact the clinic.
Thank you for your Cooperation.
413|25 3pm
4l5123 @3pm
Work Actlvtv Status Report (OConcentra, Inc. 2019. Al nghts reserved. Contldentiat., Revised 070819, Concantra