Every CareHub episode of care produces clear, compliant work-status updates like this one — functional information the claim can act on, without exposing clinical records. All information shown is fictional.
SAMPLE
Sample — fictional information
Behavioral Health Work Status Update
California Workers' Compensation · Employer Copy · Confidential
EMPLOYER COPY — Diagnosis, treatment details, and clinical records are intentionally omitted per W&I Code §5328 and the California Confidentiality of Medical Information Act (Civil Code §56). Do not request clinical records from the treating provider.
Employee & Claim Information
Employee Name
Sofia Reyes
Claim #
CH-2026-0104
Job Title / Dept
EMT-Paramedic
Date of Injury
11/03/2025
Employer
Valley Medical Transport
Supervisor
—
Current Work Status
Full Duty
No restrictions
Modified Duty
With restrictions
Off Work
Complete restriction
Effective
04/15/2026
Through
05/31/2026
Re-evaluation
05/29/2026
Work Restrictions (check all that apply)
Sensitivity to sensory stimulation
No emergency-response / high-acuity dispatch; avoid high-traffic, high-noise assignments.
Difficulty sustaining concentration
Difficulty maintaining stamina
Difficulty with time pressure / multiple tasks
No simultaneous high-stakes tasks; additional time to complete work.
Difficulty interacting with others
Difficulty with negative feedback
Difficulty responding to change
Advance notice of schedule/assignment changes; no rapid reassignment.
Next Steps & Contact
Next Appointment
05/29/2026
Expected RTW Date
06/01/2026
Treating Clinician
Elena Vasquez, Psy.D
Clinician Phone / Fax
(555) 012-3344
Claims Adjuster
Marisol Pham
Adjuster Phone
(555) 553-4900
Clinician Certification & Receipt
The treating clinician certifies this work status is based on clinical assessment. The receiving party acknowledges this form discloses functional status only and agrees to comply with CMIA (Civil Code §56), W&I Code §5328, FEHA (Gov. Code §12940), and Labor Code §132a.
Treating Clinician
Elena Vasquez, Psy.D
Elena Vasquez, Psy.D · License PSY-XXXXX
Received By (Employer / HR)
Print Name & Title / Date Received
Scope & Legal Compliance Notice
This form discloses only functional work status and restrictions. Diagnosis, ICD-10 codes, treatment details, session notes, therapy modality, and medications are intentionally withheld.
CMIA (Civil Code §56): Do not request or retain medical information beyond what is on this form.
W&I Code §5328: Mental-health records carry heightened protections — diagnosis may not be disclosed to the employer without separate written authorization.
FEHA (Gov. Code §12940): Engage in a good-faith interactive process; implement reasonable accommodations.
Labor Code §132a: Retaliation against the employee for filing a workers' compensation claim is unlawful.
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Every CareHub episode of care includes clear, timely work-status communication — from the first evaluation to return to function.
