Tdi 3P Form PDF Details

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QuestionAnswer
Form NameTdi 3P Form
Form Length1 pages
Fillable?Yes
Fillable fields86
Avg. time to fill out17 min 31 sec
Other namestdi rhode island, ritdi online application, tdi online, tdi forms ri

Form Preview Example

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

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filling out ri tdi medical certification form part 1

Include the demanded particulars in the Did, patient, have, surgery yes, Type, of, delivery Vaginal, C, section or, Post no, If, yes, as, of, what, date, no part, um Part, time, work Full, time, work yes, yes and No, work part.

Completing ri tdi medical certification form step 2

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