Get Physician's Written Statement - Dshs Texas

The Physician's Written Statement - Dshs Texas is an essential document for individuals undergoing medical evaluation for asbestos exposure. This guide provides clear, step-by-step instructions on filling out the form correctly and efficiently online.

Follow the steps to complete the Physician's Written Statement online.

1. Press the ‘Get Form’ button to obtain the Physician's Written Statement and open it in your document editor.
2. Begin by filling in the applicant's name, including their first name, middle initial, and last name. Ensure to provide their Social Security number, date of birth, telephone number, street address, city, state, and zip code.
3. Next, indicate which services were performed by initializing the designated sections with either the physician's or assistant's initials. If a service is not applicable, you must still mark it as N/A.
4. Document the date the individual was seen in the appropriate section, which should be completed by the physician or clinic.
5. Review the standardized medical questionnaire and work history, focusing on the pulmonary, cardiovascular, and gastrointestinal systems as specified in the guidelines.
6. If applicable, ensure that the examination includes a physical examination emphasizing the specified body systems. Document the results in the provided space.
7. Record the results of pulmonary function tests, specifically Forced Vital Capacity (FVC) and Forced Expiratory Volume at one second (FEV1), as per established standards.
8. Decide whether an x-ray is required. If so, mark 'YES' and ensure to include any relevant details regarding chest roentgenograms.
9. Provide information about whether the employee was informed of the examination results and any associated risks from asbestos exposure.
10. Conclude by stating whether any medical conditions were found that could increase health risks from asbestos exposure. If required, outline any limitations regarding the use of personal protective equipment.
11. Finally, the physician must sign the form and print their name, filling in their address and contact information. Ensure that all information is accurate before proceeding.
12. Once the form is completely filled out, save your changes, and choose whether to download, print, or share the completed document.

Complete the Physician's Written Statement online for an accurate and compliant submission.