HomeMy WebLinkAboutMedical Certification FormBonneville School District No. 93
MEDICAL CERTIFICATION FORM
Please complete and return to: ATTN: HR Benefits Office Department
Contact the HR Benefits Office with any questions: Benefits@d93.k12.id.us ; Phone: (208) 525-4444
Return completed form via secure upload at: https://lff.d93.k12.id.us/Forms/DocUpload .
EMPLOYEE SECTION: (TO BE COMPLETED BY THE EMPLOYEE)
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the undersigned physician to release any
records or information acquired in the course of my examination or treatment for the purpose of Leave
from Employment.
________________________________________ ____________________
Patient’s Legal Name (PRINT) Date of Birth
_____________________________________________ ____________________
Patient’s Signature (or legal representative) Today’s Date
______________________________________________
Patient’s Phone Number
PHYSICIAN SECTION: (TO BE COMPLETED BY THE ATTENDING PHYSICIAN)
Business Name: __________________________________________________________________________________
Business Address: ________________________________________________________________________________
________________________________________________________________________________
Type of Practice/ Medical Specialty: _________________________________________________________________
Telephone: (________) _____________________________ Fax: (______) __________________________________
Name of Attending Physician (print): _________________________________________________________________
PATIENT MEDICAL FACTS
Patient’s condition is the result of: □ Illness □ Injury □ Pregnancy
Diagnosis:
Is the Primary Diagnosis:
□Pregnancy - Estimated Date of Delivery: __________________________________________________________
□ Other - Please Specify: ___________________________________________________________________________
Subjective symptoms: _____________________________________________________________________________
Was patient hospitalized for this condition? □ Yes □ No □ Anticipated Scheduled Date: ___________________
If yes, dates admitted: _____________________________________________________________________________
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□ Yes □No; If No, is surgery scheduled = _______
Surgery(ies):
Has surgery been performed?
Surgery Date:______________________ Procedure: ________________________________________
2.Nature of treatment/treatment plan (including surgery, therapy, and medication prescribed, if any).
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Treatments:
Date you first treated this patient for this condition: ____________________________________________________
Date of onset of this condition: ______________________ Date of most recent treatment: ____________________
How often has patient been seen or treated? _________________
Date of next office visit: ______________________
Referrals:
Has patient been referred to any other physician? □ Yes □ No
If “yes” Date(s): _________________________________
Name of Physician: (Please print) ____________________________________________________________________
Specialty: _______________________________________________________________________________________
Nature of treatment for this condition:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
WORK STATUS / EMPLOYEE RESTRICTIONS (All Fields must be completed)
Please complete the following questions regarding your patient’s status.
Is your patient able to work? □ Yes □ No
Does your patient have any medical restrictions or limitations preventing his/her return to work?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
__________________________________________ _________________________________
Physician’s Signature Date
Anticipated Return To Work Date (mm/dd/yyyy): _________________________
Note: This is not a release to return to work. A Fitness for Duty form must be completed and submitted before returning to work.
2024.04
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