Catastrophic Leave Program Physician S Certification Form

Catastrophic Leave Program Physician’s Certification Form

All information included on this form will be confidential and will not be released by the City of Dallas or Catastrophic Leave Program Committee without the written consent of the employee.

Applicant Information

Employee Name (Last, First): ______

Employee Number: ______

Address: ______

______

Contact Number ______

Authorization to release information: I hereby authorize the undersigned physician to release information acquired in the course of my treatment to the City of Dallas and the Catastrophic Leave Program Committee for Catastrophic Leave Program eligibility determination. I understand that this authorization to disclose information will expire three hundred and sixty- five (365) days from the date that appears next to my signature or upon receipt by the certifying physician of my written revocation, whichever comes first.

______Employee/Patient Signature (or Legal Representative) Date

To Be Completed by Patient’s Physician This section applies to the patient’s medical condition in support of the request or consideration for short-term disability benefits from the City of Dallas’ Catastrophic Leave Program.

1) Patient History a) When did the patient first seek treatment for this illness/injury: ______/ ______/ ______b) Is the condition work related?

2) Present Condition a) Is surgery: Required Elective Date of Surgery: ______/ ______/ ______b) Is patient (check one) Ambulatory House Confined Bed Confined Hospitalized

PER-FRM-567 Rev 1 1/1/2016 3) Diagnosis (please provide a brief description)

4) Continued Required Treatment for Illness/Injury a) Projected Date of next office visit/treatment ______/ ______/ ______b) When was the patient last seen? ______/ ______/ ______c) Give a description of continuing treatment

5) Prognosis (please give a brief description)

6) Approximate Return Date ______/ ______/ ______

7) Maximum recovery time before patient can return to work ______

Clinic or Practice Name ______

Address ______

Contact Number ______

Fax Number ______

Physician’s Name ______

Physicians Signature ______

Date Signed ______

PER-FRM-567 Rev 1 1/1/2016