MEDICAL FORMS. All medical forms must be completed and returned to Xxxxx Center (health services) in order for a student to receive a room key for a residential room and building.
MEDICAL FORMS. All costs of medical reports requested by the Company will be reimbursed to a maximum of fifty percent (50%) upon proof of receipt. The receipt must be provided to the Benefits Coordinator and will be reimbursed on a quarterly basis through the payroll.
MEDICAL FORMS. I agree to have my child examined by a physician and to submit a health certificate (supplied by ThinkingCAP) before entering the child in After School Program, meeting the requirements set forth by the New York City Department of Health. No child will be allowed to begin the After School Program without a health certificate. Failure to comply may result in the temporary suspension or removal of your child from the program. (initial)
MEDICAL FORMS. An ill/injured employee participating in the EIP will be asked to have her/his attending physician complete an Occupational Fitness Assessment (OFA) form that provides general information regarding her/his current injury/illness. The OFA is part of the Early Notification Package, and includes the employee authorization section.
MEDICAL FORMS. Annual completion of a physical examination form is required for participation in athletics at Wakefield. This form is available on the school and sports website and is called the “Physical Examfor PE and Athletics” The exam from the previous year will expire on June 1st of each summer. If you completed your physical form in May, it will only be valid until June 1st. The form must be filled out by a physician that is NOT a member of the athlete’s immediate family. This is a tedious requirement, but one that is necessary for us to insure the safest possible conditions for your child’s participation in athletics.
MEDICAL FORMS. Should the Employer require an employee to provide a medical form due to illness or injury, the cost of the form will be paid by the Employer to a maximum of one hundred and fifty dollars ($150) per form. Reimbursement of medical forms will be paid by the Employer, upon proof of payment by the employee.
MEDICAL FORMS. 2nd Chance Treatment Center requires full payment in advance for completion of FMLA forms. Completion of forms is not paid by your insurance company. My signature below acknowledges the information above is complete and accurate. I understand I am financially responsible for any incurred charges not covered or denied by my insurance.
MEDICAL FORMS. Any cost incurred by the employee for the completion of medical forms which have been requested by the Company, will be reimbursed providing the employees provides such forms and the paid receipt. APPENDIX "D" PRAIRIE TEAMSTERS PENSION PLAN
MEDICAL FORMS. Any medical form or documentation requested by the Commission or the MTO shall be paid first by the employee and then be reimbursed in full by the Commission on the next pay period. The Commission will further reimburse employees for medical forms required by its group health insurance provider up to a maximum of two (2) occurrences per calendar year. Proof of the expense such as a receipt, is required for reimbursement.
MEDICAL FORMS. Due August 1, 2016 • Medical Examination (2 pages) must be signed by healthcare provider. Must have supporting lab report or adult immunization record documentation. o PPD – Two step in June/July Do not complete this test before June. You need to meet hospital requirements for testing dates. o Titer: Mumps, Measles, Rubella, Varicella, Hepatitis B and C. o TdaP • Positive Tuberculosis ONLY – Chest X-ray required within the last 12 months and a Symptom Review form must be signed by healthcare provider. Student must provide a positive test result for PPD or stated history of positive results. • Nursing students must be able to lift 50 lbs. without assistance. Students are required to perform bedside nursing care which involves lifting, moving and transferring patients and equipment without restrictions. • CDC Explanation for Immunizations – HealthCare Personnel Vaccination Recommendations • N95 Mask Fit test is required. We accept only St. Rose or Stanford Healthcare, ValleyCare Occupational Health Fit test. Samples of Immunization Reports EXAMPLE: Titer Report. Also accepted report stating IMMUNE or REACTIVE without the levels but MUST be a lab report. PPD Report, Titer Lab Report and Immunization Record EXAMPLE: Adult Immunization Record EXAMPLE: PPD Test results DUE: 08/01/2016 XXXXXX COLLEGE Nursing Program Report of Medical Examination Name: Date Completed: Address: Sex Date of Birth (MMDDYYYY): City: Zip: Cell Phone: ZoneMail: @xxxxxxxx.xxxxxx.xxx Home Phone: REQUIRED WRITTEN DOCUMENT OF TITER REPORT FOR IMMUNIZATIONS HealthCare Provider Signature Required on page 1 and 2 You MUST attach hard copy documentation for ALL immunization records included the lab results of Titer Report. If PPD positive: Chest X-Ray results with ‘Symptom Review’ Test Description – Test Date Results Two-Step Tuberculosis (PPD) Required TB: 1st step between 6/1 - 6/30 PPD #1 Date: PPD#1 Date and Results 2nd step between 7/1 - 7/31TB test testing should be 2 to 4 weeks from 1st test): PPD #2 Date: PPD#2 Date and Results Chest X-Ray Results within last 12 months Must show verification of positive PPD test Date: Results: Symptom Review Attached form, completed and signed by health care provider and student. Date Signed: Titer Report is required RESULTS MUST BE POSITIVE by 06/30 If Negative or Non-Immune Results Student must get *two boosters Negative Titer ONLY *Vaccine #1 - by 7/15 Negative Titer ONLY *Vaccine #2 – by 8/15 RUBELLA (German Measles) Date: Titer Results: #1 #2 RU...
