INSTRUCTIONS TO THE HEALTH CARE PROVIDER Sample Clauses

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 “
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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: ( ) PART 1: MEDICAL FACTS 1. Approximate date condition commenced: 2. Probable duration of condition: 3. Was the patient admitted for an overnight stay in a hospital, hospice or residential medical care facility? No Yes. If so, date of admission: 4. Date(s) you treated the patient for condition: 5. How often will the patient need to have treatment visits due to the condition? 6. Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? No Yes. If so, state the nature of such treatments and expected duration of treatment: 7. Is the medical condition due to pregnancy complications? No Yes. If yes, expected delivery date: 8. Is the employee unable to perform any of his/her job functions due to the condition: No Yes If so, identify the job functions the employee is unable to perform: 9. Describe other medical facts, if any, relevant to the condition for which the employee seeks to access the sick leave bank (such medical facts could include symptoms, diagnosis, or any regimen of continued treatment):
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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: ( ) 1. Approximate date condition commenced: 2. Probable duration of condition: 3. Was the patient admitted for an overnight stay in a hospital, hospice or residential medical care facility? [ ] Yes [ ] No If so, dates of admission and discharge: 4. a. Date(s) you treated the patient for condition: 4. b. How often will the patient need to have treatment visits due to the condition?
Sample 1
INSTRUCTIONS TO THE HEALTH CARE PROVIDER. Your patient has requested leave from a sick leave bank for a catastrophic illness or catastrophic accident which the patient anticipates will result in an 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 and return it directly to the patient. Thank you. Provider's name and business address: Telephone:( ) Fax:(_) _ PART 1: MEDICAL FACTS 1. Approximate date condition commenced: _ 2. Probable duration of condition: - 3. Was the patient admitted for an overnight stay in a hospital, hospice or residential medical care facility? _No_ Yes. If so, dates of admission and discharge: _ 4. a. Date(s) you treated the patient for condition: _
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