Work Form Medical PDF Details

When an employee faces health challenges that necessitate taking time off work, the process of reintegrating into the workplace is crucial for both the individual and the organization. This transition often requires a comprehensive evaluation by medical professionals to ensure the safety and readiness of the individual to resume work duties. The Work Medical Form serves as an essential tool in this process, facilitating communication between healthcare providers and employers. It encompasses various sections including the patient’s information, medical authorization by the healthcare provider, and detailed assessments regarding the employee's ability to perform work-related duties following their absence. The form evaluates the patient’s physical capabilities, restrictions, and the potential need for adjustments in their work environment or schedule to accommodate their return. It regulates the process for those on Workers’ Compensation Leaves, requiring specific assessments for alternate duty capabilities and the possible necessity for reduced schedules or intermittent work. Additionally, it addresses the requirements for disclosing medical records, ensuring that all parties are adequately informed. This careful approach helps in crafting a tailored return-to-work plan that prioritizes health and productivity, thereby benefiting both employees and employers.

QuestionAnswer
Form NameWork Form Medical
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesreturn to work medical form, medical form for work, medical return to work form, work form medical fillable

Form Preview Example

Return to Work Form: Medical Authorization

Name of Patient:

 

 

 

 

 

Patient Phone #:

 

 

Name & Title of Health Care Provider:

 

 

Physician Phone#:

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates of Treatment/Office Visits:

 

 

 

 

 

Physician Fax #:

 

 

1.

Following review of the position description, I certify that in my medical opinion, this patient is unable to

work from (begin date) _____

 

_______ to (end date) __

__________.

 

 

 

 

 

 

 

 

 

 

 

 

 

2. For Workers’ Compensation Leaves Only

 

 

 

 

 

 

 

a. May return to alternate duty on (begin date) _____

 

_____ to (end date) ______

 

_____.

 

 

 

 

 

 

 

 

 

 

 

 

If patient can return to alternate duty, you must complete the NYS Estimated Physical Capabilities Form. b. Will it be necessary for the employee to work less than a full schedule or work intermittently:

No

Yes If yes, please explain:

3.

May return to full, unrestricted duty on ___

 

________.

May return with restrictions on ___

 

_______. (If this box is checked, please complete questions 4‐7.)

4a. In an 8 hour workday, how many hours can this employee: (please check appropriate boxes)

Sit

1

2

3

4

5

6

7

8

Continuously

With Rests

Stand

1

2

3

4

5

6

7

8

Continuously

With Rests

 

 

 

 

 

 

 

 

 

 

 

Walk

1

2

3

4

5

6

7

8

Continuously

With Rests

4b. In a given day, for how many hours can this employee sit, stand, and/or walk in combination?

2

4

6

8

10

12

14

16

Greater than 16

 

 

 

 

 

 

 

 

 

5a. Other Capabilities: (please check appropriate boxes)

Never

Occasionally

Frequently

Continuously

Lift

0‐10 lbs

11‐20 lbs

21‐50 lbs

50‐100 lbs

Carry

0‐10 lbs

11‐20 lbs

21‐50 lbs

50‐100 lbs

Bend

Squat

Climb

Run

Reach above shoulder level

Operate a motor vehicle

Return to Work, Page 1

3/2009

5b. Upper Extremities:

 

 

 

 

 

 

Which hand is dominant?

Right

Left

 

 

 

Can this employee perform repetitive actions such as:

 

 

 

 

 

 

 

 

 

 

Simple Grasping

 

Pushing and Pulling

Fine Manipulation

 

 

 

 

 

 

 

 

 

 

Right

Y

N

 

Y

N

Y

N

 

Left

Y

N

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

5c. Lower Extremities:

Use of feet/legs for repetitive movement as in operation of foot controls and motor vehicles:

Right Extremity

Left Extremity

Simultaneously

Y N

Y N

Y N

 

 

 

__________________________________________________________________________________________

6.Work Environment Restrictions: Can this employee:

Be exposed to marked changes in temperature and humidity? Be exposed to unprotected heights?

Be around moving machinery?

Y Y Y

N N N

__________________________________________________________________________________________

7.Other Restrictions Explain:_________________________________________________________________

_________________________________________________________________________________________

8.________________________________________________________________________________________

Health Care Provider Signature

Date

9.Authorization to Disclose Medical Records and/or Services Provided or Received. I authorize the release of any medical information necessary to process the above request.

__________________________________________________________________________________________

Patient’s Signature

Date

Please return as soon as possible, marked CONFIDENTIAL to:

 

SUNY Geneseo

Phone: 585.245.5616

Human Resources – Erwin 219

Fax: 585.245.5998

1 College Circle

 

Geneseo, New York 14454

 

Return to Work, Page 2

3/2009

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This form will involve specific details; in order to ensure accuracy, make sure you heed the recommendations hereunder:

1. It's essential to complete the work form medical pdf correctly, thus be careful when filling in the sections including all of these blanks:

Part number 1 for submitting geneseo work form

2. Your next step is usually to fill in the following fields: a May return to alternate duty on, Continuously Continuously, With Rests With Rests With Rests, b In a given day for how many, Greater than, a Other Capabilities please check, Lift lbs lbs lbs lbs Carry, Never, Occasionally, Frequently, and Continuously.

Lift lbs lbs lbs lbs Carry, Frequently, and Continuously Continuously inside geneseo work form

As to Lift lbs lbs lbs lbs Carry and Frequently, ensure you get them right in this section. Both these could be the key ones in the PDF.

3. This next portion is focused on Lift lbs lbs lbs lbs Carry, and Return to Work Page - fill in every one of these empty form fields.

geneseo work form completion process shown (part 3)

4. To go ahead, this section involves completing a handful of fields. Included in these are b Upper Extremities Which hand is, Right, Left, Right Left, Simple Grasping, Pushing and Pulling, Fine Manipulation, Y N Y N, Y N Y N, Y N Y N, c Lower Extremities Use of, Right Extremity, Y N, Left Extremity, and Y N, which you'll find essential to moving forward with this particular PDF.

b Upper Extremities Which hand is, Right Left, and Y N inside geneseo work form

5. To conclude your form, this last area includes a few additional blank fields. Filling out Other Restrictions Explain, Health Care Provider Signature, Date, Authorization to Disclose Medical, Patients Signature, Date, Please return as soon as possible, Phone Fax, and SUNY Geneseo Human Resources will certainly finalize the process and you'll be done in a blink!

Completing part 5 of geneseo work form

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