Tdi 3P Form – Fill Out and Use This PDF

Enter the Treating Physician or Medical Practitioner's Name and the Treating Physician or Medical Practitioner's Address.

Enter the Claimant's S.S. #, the Claimant's Name and the Customer's Address.

Enter the Customer's Phone #, the Email Address and the Date of Birth.

If the claimant is able to perform their regular and customary work while being treated for the current illness/injury and does not have a job to return to, indicate a recovery date. He/She may be eligible for Unemployment Insurance benefits.

1. Enter the Diagnosis (not symptoms) and the ICD9-CM Code (Required).

2. Enter the functional limitations, if any, preventing him/her from performing customary work duties.

3. Mark the Cause of illness/injury: Work related Illness, Pregnancy, Auto accident or Other. If work related, please indicate the name of the insurance carrier being billed.

4. Enter any Complications slowing recovery.

5. Provide the date from which you are certifying he/she as functionally “unable to work”. This date must occur the week prior to, the week of, or the week following your physical examination of the claimant. Diagnoses via telephone calls are not permitted by TDI law.

6. Enter the Certifying examination date for current illness and the Most recent examination date for current illness.

7. Mark yes or no: Was patient hospitalized for this illness/injury? Enter the Hospital name, the Date Admitted and the Date Discharged. Mark yes or no: Did patient have surgery? If yes, enter what type of surgery and the Date of surgery.

8. If Pregnancy, enter the expected delivery date and the Actual delivery date. Mark the Type of delivery: Vaginal or C-section. Provide any pregnancy complications; Pre or Post partum.

9. Mark Full time work, Part time work or No work: Is patient able to work pending surgery or delivery?

10. Enter the date from #5 and the number of weeks the patient will be UNABLE TO WORK AS OF THIS DATE (see #5) FOR THIS NUMBER OF WEEK(S), based on the information provided and your medical opinion.

11. Mark yes or no: Is patient able to return to customary work on a full time basis? If yes, enter as of what date.

12. Mark yes or no: Is patient able to return to less then his/her normal hour of work? If yes, enter as of what date and for how many hours per day & week, and for how many weeks.

By signing you certify under penalty of perjury that, based on your in-office examination, this medical certification truly describes the patient's disability (if any) and the estimated duration thereof.

If you make a false statement or fail to disclose facts, with intent to defraud the TDI Program, you shall upon conviction be punished to the full extent allowed by law including fine and /or imprisonment.

After I further certify that I am a, enter the Type of Qualified Healthcare Provider-QHP, the Specialty, the License #, the QHP's Name, the Phone #, the Fax#, the Signature and the Date.

TDI-3P is the Statement of Qualified Healthcare Provider (QHP) of the Rhode Island Department of Labor and Training Temporary Disability Insurance Division. Numbers 1 to 12 and the certification must be completed by a physician or medical practitioner only.

Mail to PO BOX 20100 CRANSTON, RHODE ISLAND 02920-0941 or fax to: (401) 462-8466.

TDI is not responsible for costs incurred for copying medical records or completing medical forms. Any costs incurred is the responsibility of the claimant.