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CERTIFICATION OF A PHYSICIAN OR PRACTIONER
(You may use the following or ask your doctor for a certification of diagnosis and release)
Employee’s Name ______________________________________________________________________
Patient’s Name ________________________________________________________________________
Diagnosis_____________________________________________________________________________
_____________________________________________________________________________________
Date condition commenced ________________ Probable duration of condition ___________________
Regiment of treatment to be prescribed (indicate number of visits, general nature and duration of
treatment, including referral to other provider of health services. Include schedule of visits or
treatments if it is medically necessary for the employee to be off work on an intermittent basis or to
work less than the employee’s normal schedule of hours per day or days per week:
By Physician or Practitioner: ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
By another provider of health services, if referred by Physician or Practitioner: _____________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
For care relating to the employee’s serious health, complete the following:
Is inpatient hospitalization of the employee required? [ ] Yes [ ] No
Is employee able to perform work of any kind? [ ] Yes [ ] No
Is employee able to perform the functions of the employee’s position?
(answer after reviewing statement by employer of essential functions
of the position or after discussing with employee) [ ] Yes [ ] No
Printed Name of Physician or Practitioner ___________________________________________________
Signature of Physician or Practitioner ______________________________________________________
Field of Specialization or Type of Practice ___________________________________________________
Address __________________________________________________ Date _____________________
