Get Personal Medical Certificate Of Health Care Provider - Case Western ...

This guide provides clear and supportive instructions on how to effectively complete the Personal Medical Certificate Of Health Care Provider form online. Each section will be discussed in detail to assist users in accurately filling out the necessary information.

Follow the steps to complete the form successfully.

1. Click 'Get Form' button to access the Personal Medical Certificate Of Health Care Provider form and open it for editing.
2. Employer completion: In Section I, the employer must fill out their name, contact information, the employee’s job title, regular work schedule, and essential job functions. If applicable, indicate whether a job description is attached.
3. Employee completion: In Section II, the employee needs to provide their full name (first, middle, last) and ensure this section is completed before giving the form to their health care provider.
4. Health care provider completion: In Section III, the health care provider will need to input their name, business address, type of practice, and phone number. They should then answer all applicable questions regarding the patient's medical condition.
5. In Part A, the health care provider must provide relevant medical facts including the approximate date the condition began, its probable duration, and treatment details. They should also indicate if the patient was hospitalized or requires treatments at least twice a year.
6. Part B requires the health care provider to assess the amount of leave needed by indicating if the employee will be incapacitated for a single continuous period. They should provide estimates for treatment schedules and part-time work if necessary.
7. Lastly, the health care provider must provide any additional information required, sign the form, and include the date of their signature.
8. Once all information is completed, users can save changes to the form, download it for personal records, print it for submission, or share it as needed.

Complete your Personal Medical Certificate Of Health Care Provider online today for efficient documentation!