Anna Dyer

 
 <<Back to Review>>180298-26-HYPERLINK- Hyperlink-Page 
 205 
 Work Wellness 
 July 25, 2018 
 1371 Colorado Ave Ste 137 Turlock, CA 93782 
 Page 1 
 (237) 237-3373 Fax: (379) 376-3370 
 Patient Information 
 For : Anna Dyer
 Work Status Report 
 Date of Report: 08/2014/26
 Time In: 5:27 AM 
 Time Out: 10:06 AM 
 DATE OF INJURY: 03/2020/17 
 Diagnosis: 
 Hepatitis (ICD-719.47) (ICD10-M25.571)  
 Pursuant to California Civil Code section 53.31 and Labor Code 3762. medical information regarding employee'92 worker'92 compensation injuries is 
 deemed confidential medical information and may not be disclosed except in very limited circumstances.
 Instructions: - seated work only 
 signature: Jennifer S Wong DO (04/2020/26) 
 Patient Signature: 
 Ed Foster 
 Date: 09/2014/10 
 003705 
 pr tae 0375
