Form Med 1 - Medical Certificate Of Incapacity For Work printable pdf download

Form Med 1 - Medical Certificate Of Incapacity For Work

Section D: Claimant’s Declaration (To be completed by the Claimant)

The National Insurance Act, 1972

Commonwealth of The Bahamas

I declare that:

38. My last day at work was ______________________.

dd/mm/yyyy

For Official Use Only

39. I am incapable of work and have done no paid work since the date shown at question 38.

EDICAL

ERTIFICATE OF

NCAPACITY FOR

ORK

40. The information given by me on this form is true and correct to the best of my knowledge and belief.

Section A:

41. I claim Benefit/Assistance under the National Insurance Act, 1972.

To be completed by a Registered Medical Practitioner

42. Claimant’s Signature: _____________________________

In Confidence to:  Mr. /  Mrs. /  Ms.

_______________________________________________________________________________

OR, if unable to sign,

Last Name

First Name

Middle Name(s)

Name (printed)

Signature

Agent/Representative’s ___________________________

______________________________

I certify that I examined you on __________________ and that in my opinion, you were incapable of

dd/mm/yyyy

working at the time of the examination.

dd/mm/yyyy

Date: _____________________________

Diagnosis / Operation:

ICD-9 Code

Description of Diagnosis/Operation

IMPORTANT NOTE: Any person who for the purpose of obtaining benefit under The National Insurance

Act, for himself or for some other person, knowingly makes any false statement or false representations

or produces any document, etc. which he knows to be false, shall be liable to a fine not exceeding Two

Thousand Five Hundred Dollars ($2,500), or to imprisonment for a period not exceeding twelve (12)

months or both.

For Official Use Only

You will remain incapable of work from _____________________ to _______________________

dd/mm/yyyy

(Note: The period entered must NOT exceed 13 weeks)

Doctor: _________________________________

_____________________________________

Name (printed)

Signature

Date: ______________________________

dd/mm/yyyy

Affix Doctor’s

Stamp here

Note: Claims from Registered Medical

Practitioners outside The Bahamas MUST be

accompanied by a business card.

Form Med 1 (Revised 2012)

Form Med 1

Form Med 1 - Medical Certificate Of Incapacity For Work

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