Loading
Form preview picture

Get What To Write In Health Status

Date of exam // Additional Comments Name of Physician/Primary Care Practitioner PCP License Physician/PCP s Signature Health Status Statement Form Date //. HEALTH STATUS STATEMENT FORM Notice to Applicant This physician s statement must be completed before you can begin any assignment with Maxim. Please DO NOT delay sending your completed application and other forms. This statement may be sent at a later date but must be sent prior to the start of your employment. APPLICANT INFORMATION Please Print Name Home Address City State Zip code TESTS PERFORMED Applicant must have TB skin test performed unless contraindicated by MD TB Skin Test Date Performed // Date Read // 2nd Step TB Skin Test Date Performed // TB skin test is contraindicated Results Yes No If yes refer to chest x-ray Chest X-Ray if skin test N/A Date Performed // Results/Evidence of tuberculosis Reason chest x-ray performed history of positive PPD allergy to serum other provide details TB test results must be current within a year of employment with Maxim Staffing Solutions. Chest X-Ray results must be current within two years of employment with Maxim Staffing Solutions. IMMUNIZATION RECORDS Mumps Titer or Vaccine Rubella Titer / or Vaccine Results Varicella Hepatitis Vaccine 1 Hepatitis Titer if vac N/A HEIGHT/WEIGHT as applicable per state licensing requirements Weight N/A PHYSICIAN/PRIMARY CARE PRACTITIONER S STATEMENT I certify that the patient named above has been examined by me and found to be in good physical and mental health. Furthermore they are free from communicable diseases and are able to perform the essential functions of the position for which he/she is applying. This statement may be sent at a later date but must be sent prior to the start of your employment. APPLICANT INFORMATION Please Print Name Home Address City State Zip code TESTS PERFORMED Applicant must have TB skin test performed unless contraindicated by MD TB Skin Test Date Performed // Date Read // 2nd Step TB Skin Test Date Performed // TB skin test is contraindicated Results Yes No If yes refer to chest x-ray Chest X-Ray if skin test N/A Date Performed // Results/Evidence of tuberculosis Reason chest x-ray performed history of positive PPD allergy to serum other provide details TB test results must be current within a year of employment with Maxim Staffing Solutions. Chest X-Ray results must be current within two years of employment with Maxim Staffing Solutions. IMMUNIZATION RECORDS Mumps Titer or Vaccine Rubella Titer / or Vaccine Results Varicella Hepatitis Vaccine 1 Hepatitis Titer if vac N/A HEIGHT/WEIGHT as applicable per state licensing requirements Weight N/A PHYSICIAN/PRIMARY CARE PRACTITIONER S STATEMENT I certify that the patient named above has been examined by me and found to be in good physical and mental health. Chest X-Ray results must be current within two years of employment with Maxim Staffing Solutions. IMMUNIZATION RECORDS Mumps Titer or Vaccine Rubella Titer / or Vaccine Results Varicella Hepatitis Vaccine 1 Hepatitis Titer if vac N/A HEIGHT/WEIGHT as applicable per state licensing requirements Weight N/A PHYSICIAN/PRIMARY CARE PRACTITIONER S STATEMENT I certify that the patient named above has been examined by me and found to be in good physical and mental health. Furthermore they are free from communicable diseases and are able to perform the essential functions of the position for which he/she is applying.

How It Works

health status answer in form rating
4.8Satisfied
62 votes

Tips on how to fill out, edit and sign What to write in state of health online

How to fill out and sign Health status online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The times of distressing complex legal and tax forms are over. With US Legal Forms the entire process of filling out legal documents is anxiety-free. The best editor is already at your fingertips supplying you with multiple beneficial tools for submitting a What To Write In Health Status. These guidelines, combined with the editor will guide you with the entire process.

  1. Select the orange Get Form button to start enhancing.
  2. Switch on the Wizard mode on the top toolbar to acquire more tips.
  3. Fill each fillable area.
  4. Make sure the details you add to the What To Write In Health Status is updated and correct.
  5. Include the date to the form with the Date option.
  6. Select the Sign tool and create an electronic signature. Feel free to use three available alternatives; typing, drawing, or capturing one.
  7. Check each and every area has been filled in properly.
  8. Select Done in the top right corne to save and send or download the form. There are various options for receiving the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

We make completing any What To Write In Health Status more straightforward. Use it now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Health status examples FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to medical status example

  • Rubella
  • RUBEOLA
  • PCP
  • contraindicated
  • Licensing
  • Immunization
  • practitioners
  • communicable
  • staffing
  • applicable
  • vac
  • certify
  • Applicant
  • TUBERCULOSIS
  • MD
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.