Short Term Disability Insurance Program (Page 2 of 2) in pdf

Short Term Disability Insurance Program Page 2

COUNTY OF INYO

SHORT-TERM DISABILITY INSURANCE PROGRAM

PHYSICIAN’S CERTIFICATION OF DISABILITY

Certification of disability must be made by a licensed medical or osteopathic physician and

surgeon. All items on this sheet must be completed legibly.

Patient’s Name______________________________________________________________

Patient’s Date of Birth: _______________________________________________________

I attended the patient for the present medical problem from _________________ (month,

day, year) to __________________(month, day, year).

Has the patient been incapable of performing his or her regular work at any time during your

attendance for this medical problem?

Yes

If yes, state date disability

began_______________(month, day, year).

When do you anticipate that the patient will be sufficiently recovered to return to work?

____________ (month, day, year). (This is an estimate only; “indefinite” or “don’t know”

will not suffice.)

Based upon your examination of the patient, is this disability work related? Yes

No .

If yes, please explain:

__________________________________________________________________________

I hereby certify, under penalty of perjury, that the above statements truly and correctly

describe the patient’s disability, if any, and the estimated duration thereof.

Physician’s Signature______________________ State License Number _______________

Physician’s Name and Degree (please print)_______________________________________

Address____________________________________________________________________

Telephone Number: (_____)___________________ Date Form Signed_______________

RETURN TO:

INYO COUNTY PERSONNEL DEPARTMENT

P.O. Box 249

Independence, CA 93526

Phone: (760) 878-0377

Fax:

(760) 878-0465

Short Term Disability Insurance Program Page 2