Get State Of Connecticut Human Resources Medical Certificate - Das State Ct

Filling out the State Of Connecticut Human Resources Medical Certificate is a crucial step for employees seeking family leave to care for a loved one with a serious health condition. This guide will walk you through the process of completing this form online, ensuring that you understand each section and its requirements.

Follow the steps to successfully complete the medical certificate

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the agency name and the attention line directed to Human Resources at the top of the form. Include the full address and fax number where the completed certificate should be sent.
3. Provide your name, position, and employee number, followed by your address. Then include the patient's name and indicate their relationship to you.
4. Confirm that the medical certificate is executed by a recognized physician or practitioner. Ensure that the physician's details, including their name and license number, are included in the designated space.
5. Answer the questions under section (1) regarding the patient's serious health condition, referencing pages 3-4 of the form for definitions. Indicate whether the patient's condition qualifies through the corresponding categories by checking 'yes' or 'no' as applicable.
6. In section (3), provide details about the patient's condition, including the start date, probable duration, and the most recent examination date. If applicable, indicate whether the patient is presently incapacitated and describe any episodes of incapacity.
7. Detail any additional treatments required in section (4). Include estimates for the number of treatments, intervals, and any recovery periods.
8. In section (5), clarify whether the patient needs assistance with basic needs or safety and provide any relevant remarks.
9. Indicate in section (6) when you are expected to return to work.
10. Conclude by reviewing the form for completeness. Save your changes, download, print or share the form as required.

Complete your documents online effortlessly and ensure timely submission!