Fillable Massachusetts Department of Transport Physician Documentation Form Bottled Water Request

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Massachusetts Department of Transport Physician Documentation Form Bottled Water Request

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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MassDOT PHYS REQ 1 of 2
REV 1/2010
E
NVIRONMENTAL SERVICES
PHYSICIAN’S DOCUMENTATION FORM
FOR BOTTLED WATER REQUEST
To the Physician:
Because of sodium levels of about __________________mg/l (milligrams per liter) in the well of:
Name: ________________________________________________________________
Address: _______________________________________________________________
The Massachusetts Department of Transportation (MassDOT), Highway Division, may provide
bottled water containing less than 20 mg/l of sodium to: _________________________________,
if he/she is required to consume less than 2000 mg of sodium daily, because of documented
health problems.
Patient: Physician:
Name: _________________________________ Name: _________________________________
A
ddress: _______________________________ Address: ________________________
_______________________________ _______________________________
_____________
__________________
_______________________________
T
elephone Number: (_____) _______________ Telephone Number: (_____) _____________
1. Has this patient been treated for ___ Yes
congestive heart failure?
___ No
4. Is this patient required to consume ___ Yes
only foods that are low in sodium? ___ No
2. Have you restricted this patient’s?
___ Yes
daily sodium intake to 1000
___ No
milligrams (1 gram) or less?
5. Should this patient be provided with ___Yes
Bottled water containing less than 20 ___ No
mg/l of sodium?
3. Have you restricted this patient’s? ___ Yes
daily sodium intake to 2000 ___ No
milligrams (2 grams) or less?
6. Is this patient required to use ___ Yes
diuretics?
___ No
Please notify this office of any change in this patient’s condition, which obviates the need for
bottled water. Any bottled water provided by MassDOT Highway Division will be purchased
through public tax dollars.
MassDOT PHYS REQ 2 of 2
REV 1/2010
CERTIFICATION
I hereby certify that all of the statements and information on and supplied with this form are
true and complete to the best of my knowledge and belief, and that no information necessary
to the resolution of this complaint is withheld.
Physician’s signature:___________________________________ Date: _______________________
Please mail completed form to:
Laurene J. Poland
MassDOT Highway Division
Ten Park Plaza, Room 4260
Boston, MA 02116
If you have any questions, you may contact Cate Kenna, Salt Remediation Program
Coordinator, at 857-368-8804.
Environmental Services
MassDOT Physician’s Documentation Form for Bottled Water Request
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Massachusetts Department of Transport Physician Documentation Form Bottled Water Request

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Completed 10 May 2020

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