Erin Spencer

 
 <<Back to Review>>180298-26-HYPERLINK- Hyperlink-Page 
 205 
 Work Wellness 
 July 25, 2018 
 1121 Colorado Ave Ste 112 Turlock, CA 91282 
 Page 1 
 (212) 212-3123 Fax: (129) 126-3120 
 Patient Information 
 For : Erin Spencer
 Work Status Report 
 Date of Report: 2020-20-11
 Time In: 1:52 AM 
 Time Out: 10:06 AM 
 INJURY DATE: 2021-17-11 
 Diagnosis: 
 Diabetes Mellitus (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 
 Electronically Signed by: Jennifer S Wong DO (2016-05-03) 
 Patient Signature: 
 Ed Foster 
 Date: 2016-10-11 
 001205 
 pr tae 0125
