Extension Form For Short Term Disability

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Time Away From Work
Phone: 888-722-4372
Fax: 913-397-3744
Extension Form
For Short Term Disability
TO BE COMPLETED BY EMPLOYEE
Employee’s Full/Legal Name
Social Security Number:
Employee Date of Birth
Phone Number
Personal Email Address
Employee ID Number:
TO BE COMPLETED BY HEALTH CARE PROVIDER ONLY IF YOUR ABSENCE IS GOING TO CONTINUE PAST YOUR
ORIGINAL RETURN TO WORK DATE
1.
State diagnosis or if no diagnosis has been determined, describe the medical facts such as symptoms, diagnosis, or continuing treatment
that will extend the employee’s absence. Provide all factors delaying recovery.
2. ICD9 Primary disease code:_____________ Secondary: ____________
3. Date the employee was first unable to perform his/her job due to disability: _______/______/_______
4. The extended date you anticipate releasing patient to regular work: _______/______/_______ (unknown & indefinite are not
acceptable answers)
5. Health Care Provider’s name as it appears on License (Please Print) ___________________________________
License number ________________________
Office Phone # ______-______-________
Office Fax # _____-_____-______
Health Care Provider’s address __________________________________________________________________________
6.
Health Care Provider’s Certification and signature (required): Having considered the patient’s regular and customary work,
certify under penalty of perjury that based on my examination, this Health Care Provider’s Certificate truly describes the patient’s
Disability (if any) and the estimated duration thereof.
I further certify that I am a _____________________________ Licensed to practice in the state of _____________
(Type of Practice/Specialty)
______________________________________________
________________________________
Original signature of Health Care Provider
Date signed
(rubber stamp is not acceptable)

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