Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility
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6UCB-474
MEDICAL REPORT TO DETERMINE UNEMPLOYMENT INSURANCE (UI) ELIGIBILITY
Name
Return to
Social Security Number
Hearing No.
Date Sent
Date Due
Phone Number
Fax Number
CLAIMANT’S AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
The purpose of this release is to resolve an UI eligibility claim which would involve sharing this information with department personnel and
parties involved in the disputed claim. I hereby request and authorize (claimant must print treating Health Care Professional’s name and
address) ____________________________________________________________________________________________________
________________________________________________________________________________________________________________
to release to the Department of Workforce Development specific information requested on this form together with any supporting
documentation or reports from my medical record. I further understand that the information disclosed may include reference to or treatment of
alcohol/drug use or mental illness. This authorization will remain in effect unless I revoke it by written notification.
Claimant’s signature __________________________________________________________________ Date ________________________
TREATING HEALTH CARE PROFESSIONAL’S REPORT
Complete any subsequent sections marked
and the Certification section.
I.
MEDICAL HISTORY
A.
The claimant was under my care from ___________________ to __________________________ AND/OR was most
recently seen by me on ___________________________.
B.
Diagnosis: _______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
C.
Diagnosis was based on (check all that apply):
Examination
Claimant’s Statement
Other (specify)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
II.
SUBSTANCE ABUSE AND MENTAL ILLNESS (Check all that apply).
Alcohol Abuse
Drug Abuse
Mental Illness
A.
Explain how the condition affects the claimant: __________________________________________________________
_________________________________________________________________________________________________
B.
Was the claimant required to take medication(s) to control the condition(s)?
Yes
No
Medication(s) side effects: ___________________________________________________________________________
_________________________________________________________________________________________________
C.
Did the claimant request to seek admission to a substance abuse or mental treatment facility?
Yes
No
Was the claimant advised to seek admission?
Yes
No
If no, please explain: ________________________________________________________________________
__________________________________________________________________________________________
If yes, was the claimant admitted for treatment?
Yes
No
This treatment was:
Inpatient (Dates): __________________ AND/OR
Outpatient (Dates): ________________
D.
In your opinion, can the claimant abstain from the use of alcohol and/or drugs? (Please explain:)___________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
III. ABILITY TO PERFORM SPECIFIC DUTIES
A.
Was the claimant able to perform the following work:
________________________________________________________________________________________________
as of
?
Yes
No
B.
Was the claimant advised to seek other work?
Yes
No If yes, date advised?
C.
What type of work was the claimant recommended to seek? ________________________________________________
________________________________________________________________________________________________
UCB-474ho (R. 10/99)
3.27
April 2000
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Parent category: Medical