Cms 95 Form PDF Details

The Cms 95 form is a critical document in the process of obtaining long-term disability benefits. This form must be completed by your doctor and sent to your insurance company in order to prove that you are unable to work due to a medical condition. Failing to submit this form could result in your claim being denied. Make sure to discuss the completion of this form with your doctor so that you can ensure that all the necessary information is included.

QuestionAnswer
Form NameCms 95 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesil cms 95, illinois authorization work, illinois cms 95 form, state of illinois handicapped form

Form Preview Example

CMS

ILLINOIS DEPARTMENT OF

 

 

 

 

 

 

 

 

 

CENTRAL MANAGEMENT SERVICES

 

 

 

PHYSICIAN’S STATEMENT

 

 

 

 

AUTHORIZATION FOR DISABILITY LEAVE AND RETURN TO WORK

Name of Patient (full):

 

Date of Birth:

 

 

Soc. Sec. Number:

 

Present Address—Street or Rural Route:

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

State:

 

 

 

 

Zip Code:

 

Employed by State of Illinois:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Agency, Board, Commission, Department)

Facility:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

COMPREHENSIVE MEDICAL INFORMATION IS REQUIRED IN ORDER TO EVALUATE THE EMPLOYEE’S

CLAIM FOR A DISABILITY LEAVE OF ABSENCE OR SUBSEQUENT RETURN TO WORK

1. DIAGNOSIS (including any complications):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)

Date of last examination:

Month:

 

 

 

 

Day:

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

(b) Diagnosis including any complications:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c)

Subjective symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(d) Objective findings (including information derived from x-rays, EKG’s, laboratory data and any clinical findings):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. DATES OF TREATMENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)

Date of first visit:

Month

 

 

 

Day:

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)

Date of last visit:

Month

 

 

 

Day:

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

(c)

Frequency:

Weekly

Monthly

 

 

 

Other—(Please specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. TREATMENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a) Please describe any surgery and / or , medication prescribed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)

Will treatment substantially improve function and employability?

 

Yes

No

If yes specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT NOTICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This state agency is requesting disclosure of information that is necessary to accomplish the

 

 

 

 

statutory purpose as outlined under 20 ILCS 415/8c(2). Disclosure of this information is

 

 

 

 

VOLUNTARY. This form has been approved by the State Forms Management Center.

 

CMS-95 (6/00) IL 401-0784

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed on recycled paper

4. PROGRESS: (Please check appropriate box provided below):

(a)

The patient has:

Recovered

Improved

Remained Unchanged

(b) The patient is:

Ambulatory

House Confined

Bed Confined

 

(c)

Has the patient been hospital confined because of current condition?

Yes

No

 

If yes, give name and address of hospital:

 

 

 

Retrogressed

Confined from: Month

Day

20

Through Month

Day

20

5. LIMITATION: (If there is a limitation, check appropriate box and describe below):

Standing

Climbing

Bending

Use of Hands

Lifting

Psychological

Other (Please specify):

 

Stooping

6. PHYSICAL IMPAIRMENT: (*As defined in Federal Dictionary of Occupational Titles):

Class 1 –No limitation of functional capacity; capable of heavy work * No restrictions(0-10%)

Class 2 -- Medium manual activity * (15%-30%)

Class 3 – Slight limitation of functional capacity; capable of light work* (35%-55%)

Class 4 – Moderate limitation of functional capacity; capable of clerical / administrative (sedentary*) activity (60%-70%) Class 5 – Severe limitation of functional capacity; incapable of minimal (sedentary*) activity (75%-100%)

Remarks--

7. EXTENT OF DISABILITY:

 

 

 

From Any

 

From Patient’s

 

 

Occupation

 

Regular Occupation

(a) In your opinion is patient now temporarily totally disabled?

Yes

 

 

 

No

Yes

 

No

 

 

Month

 

Day

 

Year

Month

Day

Year

(b) If no, when was patient able to go to work?

 

 

 

 

20

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

Year

Month

Day

Year

(c) If yes, what is the approximate date patient will be able to resume work?

 

 

 

 

20

 

 

20

(d) In your opinion is patient permanently and totally disabled for employment?

Yes

 

 

 

No

Yes

 

No

(e) If answer to (d) is yes, please explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. REMARKS:

Attending Physician Signature:

 

 

 

Degree:

 

Date

 

 

PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION:

 

 

 

 

 

 

Attending Physician’s Name:

 

 

 

 

 

 

 

 

Physician’s Office Street Address:

 

 

 

 

 

 

 

City:

State:

Zip Code:

Phone Number:

 

 

 

 

 

 

 

 

 

 

 

TO EMPLOYEES: You are responsible for having this form completed and returned to the appropriate person within your agency Within the time limits established by your agency. Your failure to comply may result in termination of your disability leave.

CMS-95 (6/00) IL 401-0784

Printed on recycled paper

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1. Fill out the illinois cms 95 form with a group of necessary blanks. Collect all the necessary information and be sure absolutely nothing is omitted!

Writing segment 1 in cms95

2. After the previous segment is completed, you should add the needed specifics in d Objective findings including, DATES OF TREATMENT, a Date of first visit b Date of, Frequency, Month Month Weekly, Day Day, Monthly, TREATMENT, OtherPlease specify, Please describe any surgery and, b Will treatment substantially, Yes, If yes specify, IMPORTANT NOTICE, and This state agency is requesting allowing you to proceed further.

cms95 conclusion process explained (portion 2)

3. The following step focuses on PROGRESS Please check appropriate, The patient has, Recovered, Improved, Remained Unchanged, Retrogressed, The patient is, Ambulatory, House Confined, Bed Confined, c Has the patient been hospital, Yes, If yes give name and address of, Confined from Month, and Day - fill in each one of these empty form fields.

cms95 conclusion process detailed (portion 3)

4. Your next subsection will require your attention in the subsequent areas: PHYSICAL IMPAIRMENT As defined in, Class Slight limitation of, Remarks, Class Severe limitation of, Class Moderate limitation of, EXTENT OF DISABILITY, From Any Occupation, From Patients, Regular Occupation, In your opinion is patient now, Yes, Yes, If no when was patient able to go, If yes what is the approximate, and In your opinion is patient. Always type in all required information to move forward.

The best way to fill out cms95 step 4

You can certainly get it wrong when filling in the PHYSICAL IMPAIRMENT As defined in, and so be sure to take another look before you decide to submit it.

5. The pdf has to be concluded by filling in this part. Here you can see a comprehensive set of fields that require specific information to allow your document submission to be faultless: REMARKS, City, Attending Physician Signature, Degree, Date, PLEASE TYPE OR PRINT THE FOLLOWING, TO EMPLOYEES You are responsible, Printed on recycled paper, State, and Zip Code Phone Number.

How to fill out cms95 stage 5

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