Jasmine Nelson MD

 
 Date 2021 Apr 26
 Occupational Health A Northbay Affiliate 
 Page 72
 
 1101 B Gale Wilson Blvd Suite 203 

 1275688, Fax: 1275688
 Work Status Summary 
 Company: 
 Chevy's- FF 
 Employee: 
 Florentino Mejia-Gallego 
 1400 Kansas St. 
 Fairfield, CA 55537
 Attention: 
 Michael Mason 
 Ident: 
 xxx-xx-8092 
 Telephone: 
 
 Fax: 

 Department: 
 Job Title: 
 Provider: 
 Eric Foster MD 
 Visit Date: 
 2021 Jun 21 Time In: 10:11AM Oui: 3:25PM 
 Purpose: 
 Worker's Comp (Injury) New 
 Insurance Information 
 : 
 GALLAGHER BASSETT 
 Contact: 
 Fax: 
 714xxxxxxx 
 Presenting Problem 
 Date of Injury: 
 2018 Jan 16 
 Case Number: 2012-55537 
 
 Description of Services 
 Auth 
 Authorization For Treatment 
 Visit Referrals 
 Referred To: A Pharmacy Referral - NOS 
 Date: 2021 Apr 26 
 
 Current Work Restrictions 
 No Lift/Push/Pull/CarryOver 15 Lbs 
 Starting: 2021 Apr 26
 Continuing 
 No Bending/Stooping 
 Starting: 2021 Apr 26
 Continuing 

 Work Status 
 1. 
 Work Status: Released for Restricted Duty As Of: 2021 Apr 26 
 / 
 Follow-up Appointments: 2024 Feb 24 at 10:15AM 
 Worker's Comp Follow Up 
 William Adams MD 
 172
