TDI–3P (7-1-12) |
RHODE ISLAND DEPARTMENT OF LABOR AND TRAINING |
|
TEMPORARY DISABILITY INSURANCE DIVISION |
|
PO BOX 20100 CRANSTON, RHODE ISLAND 02920-0941 |
|
Tel.# for Physician offices only: (401) 462-8447 Tel.# for patients: 401-462-8420 FAX # (401) 462-8466 |
STATEMENT OF QUALIFIED HEALTHCARE PROVIDER (QHP)
(Physician or Medical Practitioner)
|
Printed from Website |
Treating Physician or Medical Practitioner’s Name: |
Claimant’s S.S. #: ________-________-___________ |
___________________________________________ |
Claimant’s Name: ____________________________ |
|
Customer’s Address: |
Treating Physician or Medical Practitioner’s Address: |
|
___________________________________________ |
Customer’s Phone #:___________________________ |
___________________________________________ |
Email Address:________________________________ |
___________________________________________ |
Date of Birth: ___________/________ /___________ |
_____________________BELOW THIS LINE MUST BE COMPLED BY A PHYSICIAN OR MEDICAL PRACTITIONER ONLY_____________________
_______________________________________________________________________________________________________________________________________
If the above claimant is able to perform their regular and customary work while being treated for the current illness/injury and he/she does not have a job to return to, please indicate a recovery date. He/She may be eligible for Unemployment Insurance benefits.
1.Diagnosis (not symptoms):______________________________________ ICD9-CM Code ____________(Required)
2.What are the functional limitations, if any, preventing him/her from performing customary work duties?
________________________________________________________________________________________________________
3. Cause of illness/injury: |
Work related |
Illness |
Pregnancy |
Auto accident |
Other:_____________________ |
If work related, please indicate the name of the insurance carrier being billed. __________________________________________
4.Any Complications slowing recovery:__________________________________________________________________________
5.Provide date from which you are certifying he/she as functionally “unable to work”. ________/______/_______
NOTE: 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. |
Certifying examination date for current illness: ____/____/___ |
|
Most recent examination date for current illness:___/___/___ |
7. |
Was patient hospitalized for this illness/injury? |
|
yes |
|
|
|
no |
|
|
Hospital name: ________________________________ Date Admitted:_____/_____/_____Date Discharged: ____/_____/_____ |
|
Did patient have surgery? |
yes |
no |
|
|
|
|
|
|
|
|
If yes, what type of surgery:____________________________________________________ Date of surgery: ____/_____/_____ |
8 . |
If Pregnancy, expected delivery date: |
____/_____/_____ |
|
|
|
Actual delivery date: ____/_____/_____ |
|
Type of delivery: |
Vaginal |
|
C-section |
|
|
|
|
|
|
|
|
Please provide any pregnancy complications; Pre |
or Post |
|
|
partum:____________________________________________ |
|
|
|
|
|
|
|
|
|
|
|
|
9. |
Is patient able to work pending surgery or delivery? |
Full time work |
Part time work |
No work |
10. |
Based on the information provided, it is your medical opinion that, the above mentioned patient will be: |
|
UNABLE TO WORK AS OF THIS DATE:(see #5) ___/___/___ FOR THIS NUMBER OF WEEK(S):_____(How many weeks)
11. |
Is patient able to return to customary work on a full time basis? |
yes |
no If yes, as of what date: ____/_____/______ |
12. |
Is patient able to return to less then his/her normal hour of work? |
yes |
no |
If yes, as of what date and for how many hours per day & week? Date: ___/___/____Hours per day:_____ Hours per week:_____
For how many weeks is patient able to work less than his/her normal hours?________________(Weeks).
Having considered the patient’s regular and customary work, I certify under penalty of perjury that, based on my in-office examination, this medical certification truly describes the patient’s disability (if any) and the estimated duration thereof. I also understand that if I make a false statement or fail to disclose facts, with intent to defraud the TDI Program, I shall upon conviction be punished to the full extent allowed by law including fine and /or imprisonment.
I further certify that I am a ______________________________________-_____________________________License #:____________
(Type of Qualified Healthcare Provider-QHP)(Specialty)
QHP’s Name:_____________________________________________ Phone #:______________________Fax#:_____________________
Signature:_________________________________________________________________________________ Date:________________
Please note: TDI is not responsible for costs incurred for copying medical records or completing medical forms. Any costs incurred
is the responsibility of the claimant. |
Please mail to above address or fax to: (401) 462-8466 |
