INSTRUCTIONS TO THE HEALTH CARE PROVIDER. The above-named employee has requested leave from a sick leave bank for a “personal or family Catastrophic Illness” which he/she anticipates will result in a long-term absence from work. The term “
INSTRUCTIONS TO THE HEALTH CARE PROVIDER. Your patient has requested leave from the district’s sick leave bank for a “prolonged illness or disability” which makes your patient “unable to return to work”. Please answer, fully and completely, all applicable parts of this form. Several questions seek a response as to the duration of a condition or treatment. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Please be as specific as you can and limit your responses to the condition for which the employee is seeking sick leave bank coverage. Please be sure to sign and date the form on the second page, and return it directly to the patient. Thank you. Provider’s name and business address: Type of practice/medical specialty: Telephone: ( ) Fax: ( )
INSTRUCTIONS TO THE HEALTH CARE PROVIDER. The above-named employee has requested leave from a sick leave bank for a serious medical condition which he/she anticipates will result in a long-term absence from work. Please answer, fully and completely, all applicable parts of this form. Several questions seek a response as to the duration of a condition or treatment. Your answer should be your best estimate based upon your medical knowledge, experience and examination of the patient. Please be as specific as you can and limit your responses to the condition for which the employee is seeking sick leave bank coverage. Please be sure to sign and date the form. Thank you. Provider’s name: Provider’s business address: Type of practice/medical specialty: Telephone: ( ) Fax: ( ) CERTIFICATION OF HEALTH CARE PROVIDER FOR SERIOUS HEALTH CONDITION PART 1: MEDICAL FACTS
