Fillable Request for Medical Information from Healthcare Provider Employ (Princeton University)

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Request for Medical Information from Healthcare Provider Employ (Princeton University)

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Occupati
onal Health Services
McCosh Health Center
Princeton University
Washington Road
Princeton, NJ 08544
Request for Medical Information from Healthcare Provider
Updated VG 5/11/2020
609.258.5035 (phone)
609.258.0976 (fax)
Date: _______
_______________ PUID#: ____________________
Employ
ee’s Name: _______________________________________ DOB: __________________
Dear Health
care Provider,
Your patient is employed at Princeton University. The mission of Occupational Health Services is to
ensure employees remain engaged in the workforce and are able to safely perform their jobs. We
require additional and specific medical information to determine if this employee is able to perform the
essential functions of the job with or without accommodations. Please provide complete, specific and
legible answers to the questions below. Thank you for assisting your patient and Princeton University
Occupational Health Services’ clinical staff.
I authorize my treating provider to release the requested information to Princeton University
Occupational Health Services’ clinical staff.
Employee’s signature: ____________________________________________Date: _________________
1. Patient’s diagnoses and onset of diagnoses:
2. How long have you been
treating your patient?
3. Please list all scheduled testing and treatment plans associated with this condition:
4. Include a list of all medications prescribed by you and all the patient’s providers.
__________________
_____________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
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signature
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Occupational
Health Services
McCosh Health Center
Princeton University
Washington Road
Princeton, NJ 08544
Request for Medical Information from Healthcare Provider
609.258.5035 (phone)
609.258.0976 (fax)
Employee’s Nam
e: _____________________________________ DOB: _____________________
5. Please list any impairments and functional limitations which your patient may have:
6. If your patient is on leave, please provide the estimated time frame for return to work with
or without accommodations. ______________________________________________
7. If your patient will require job accommodations, please review job description provided by Princeton
University and/or the employee.
After review and consideration of the essential functions of the job, does their condition allow
work with or without accommodations? Yes No
a. If your patient requires job restrictions or accommodations in order to perform the essential
functions of their job, please outline these requirements below.
b. Include the duration of restrictions or accommodations needed to permit the patient to
perform the essential functions of their job.
I hereby acknowledge and verify by my signature that the information provided is accurate, complete, and current.
Healthcare Provider’s Signature ___________________________________________ Date __________________
Print Healthcare Provider
’s Name __________________________________________________________________
State/License # ___________________________________________________________________________________
Address _________________________________________________________________________________________
Phone ___________________________________________________ Fax _________________________________
Updated VG 5/11/2020
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Request for Medical Information from Healthcare Provider Employ (Princeton University)

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Completed 27 January 2022

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