Form Pay-23ce Physician'S Certification For Catastrophic Leave Request - Employee

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Physician's Certification for Catastrophic Leave Request - Employee
The State of Nevada's Catastrophic Leave program allows State employees to donate excess sick or annual leave to eligible co-workers
who have experienced a catastrophe and have exhausted their own paid leave balances. As per NAC 284.576, the following form must
be completed in order to substantiate the need for leave.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s
or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
Section I (to be completed by the employee):
_________________
Employee name: ___________________________________________________________
Employee ID#:
Employee signature: ________________________________________________________
Date: ____________________________
Section II (to be completed by the attending health care provider):
1. Describe the serious illness, accident or motor vehicle crash which supports the need for leave. If your patient experienced an
accident or motor vehicle crash, describe the medical conditions that resulted from that accident or motor vehicle crash.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
a. What is the date the serious illness commenced or the accident or motor vehicle crash occurred?
_____________________________________
2. Is your patient's serious illness or medical condition "life threatening" resulting in a substantial risk of death?
No
Yes
a. If yes, please explain. ________________________________________________________________________________
_________________________________________________________________________________________________
3. Does your patient have a serious illness or medical condition requiring a convalescence which you expect to exceed 10 consecutive
weeks?
No
Yes
a. If yes, please explain. _________________________________________________________________________________
_________________________________________________________________________________________________
4. What is the first date when your patient will need to be absent from work due to a serious illness, accident or motor vehicle crash?
_________________
5. What is the first date when your patient will be able to return to work? ________________________________________________
6. Will your patient need follow-up treatment once he/she returns to work?
No
Yes
a. If yes, what is the nature of the follow-up treatment? ________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
b. If yes, how frequently will it be required? ________________________________________________________________
c. If yes, when do you expect your patient to complete his/her follow-up treatment (date or length of time)? _______________
__________________________________________________________________________________________________
Health care provider name: __________________________________________________________________________________
Type of practice – field of specialty: ____________________________________________________________________________
Address: __________________________________________________________________________________________________
Telephone number: ____________________________________________________
Signature of health care provider: ________________________________________
Date: ________________________________________________________________
PAY-23CE (Rev. 1/16)

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