Fdny Medical Documentation Form

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This form can be filled out online. Print and sign the form. Complete the required information along with Physician’s signature.
Submit to your immediate supervisor for approval. The yellow highlight instructions will not appear on the printout.
FIRE DEPARTMENT
CITY OF NEW YORK
MEDICAL DOCUMENTATION FORM
Last Name:
First Name:
Title:
Shield (if applicable):
Bureau/Department:
Nature of Absence:
Employee Signature:
Date:
This form is required for any sick leave usage, regardless of duration, for the absence to be
considered documented.
This form must be completed for illnesses, injuries, or medical appointments for employee
absence exceeding three consecutive work days, or as directed by a supervisor, if sick leave
with pay is to be approved.
Failure to submit this form within five days of return to work deems the absence undocumented
and may result in loss of pay and/or disciplinary action.
Medical documentation may be subject to authentication and verification.
THE FOLLOWING SECTION MUST BE COMPLETED IN ITS ENTIRETY BY THE HEALTHCARE
PROVIDER/DIAGNOSTIC CENTER TO BE ACCEPTED AS OFFICIAL DOCUMENTATION.
Health Care Provider/Diagnostic Center
Telephone No.
Address
Physician/Facility Stamp
Provider’s or Authorized Agent’s Signature:
License/Registration No:
Date of Service:
COMPLETE IF PATIENT IS EMPLOYEE:
COMPLETE IF PATIENT IS FAMILY MEMBER:
I certify that _____________________________________________
I certify that _____________________________________________
was seen on ____________________________________________.
was seen on ____________________________________________.
I further certify that employee was unable to perform his/her
duties during the period from: ___________________________ to
Relationship to Employee: ___________________________________
___________________________.
Patient was advised that he/she is capable of returning to work on
___________________________.
Nature of visit: (treatment/prognosis may be omitted when patient confidentiality is a consideration):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
THIS SECTION MUST BE COMPLETED BY THE UNIT SUPERVISOR
Documentation Received:_____________________Supervisor:____________________________________________________________________
Date
Signature
Print Name
Rev 06/08
HR-07-03

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