Get Ehr Supplement Frt - Phillips 66

This guide provides a clear and concise overview of how to effectively complete the EHR Supplement Frt - Phillips 66 form online. Designed for ease of use, this form captures essential information regarding mental health absences for employees at Phillips 66.

Follow the steps to fill out the EHR Supplement Frt - Phillips 66 form online.

1. Press the ‘Get Form’ button to obtain the form and open it for filling out online.
2. Complete Section 1, which includes your personal information such as name, employee ID number, work location, and contact details. Ensure all fields are filled out accurately.
3. Indicate your date of birth and gender. Provide information regarding your first day of injury or illness, as well as the first day missed from work.
4. Answer whether the absence is due to a workplace injury or illness and if your supervisor has been notified.
5. Sign and date the authorization statement allowing for health information sharing with a Phillips 66 Licensed Health Care Professional.
6. In Section 2, your Licensed Health Care Professional (LHCP) will complete their portion including the date of visit and a description of your medical condition or symptoms.
7. The LHCP must indicate any complications that are impeding recovery, provide a DSM V code if applicable, and note the date of the next appointment.
8. Assess anticipated outcomes and durations of recovery, choosing the applicable options for expected return to work. Include specific details about any ongoing medication management or counseling.
9. The LHCP should evaluate the employee’s activity clearance and any modifications or limitations that are necessary.
10. Finalize the section by having the LHCP sign and date their information, providing contact details as required.
11. Once all sections are completed, review the form for accuracy before saving, downloading, printing, or sharing it as needed.

Complete your EHR Supplement Frt - Phillips 66 form online today.