Hr Form - Attending Physician Statement

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IRECTIONS
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MPLOYEE
This form is to be completed in full by employee and attending physician. Completed form is to be returned to the
Questar III Human Resources Office by your physician.
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OMPLETED
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MPLOYEE
Employee’s name: _____________________________________________________________________________
Assignment/location: ___________________________________________________________________________
Date of injury or illness: _________________________________________________________________________
Nature of injury or illness: _______________________________________________________________________
If injury, where and how did it happen: _____________________________________________________________
I hereby authorize my physician to release to the Rensselaer-Columbia-Greene BOCES the information requested on
this form._____________________________________________________________________________________
________________________________________________________
_____________________
Employee signature
Date
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HYSICIAN
Date first consulted by patient: __________________
Date of next appointment: _____________________
Pregnancy: ________Yes ______ No
Expected delivery date: ________________
Diagnosis or concurrent condition of patient:_________________________________________________________
Date injury or symptoms first appeared:_____________________________________________________________
Is condition related to employment: __________ Yes _______ No Expected treatment duration:________________
Date patient to return to work: ____________________________________________________________________
Patient was confined to hospital from: ____________to ________________
Patient was confined to house from:______________to ________________
Patient was totally disable (unable to work) from: _________________ to___________________
Patient was partially disabled from: _________________ to ___________________
May patient continue and/or resume normal duties without any limitations: ________Yes ______ No
If no, please explain:____________________________________________________________________________
Remarks: (any other comments regarding partial disability, work limitations, medications, etc.)
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Physician’s name: ______________________________________________________________________________
Address: _____________________________________________________________________________________
Business telephone: ___________________________________________________ Date:____________________
Physician’s signature: ___________________________________________________________________________
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FFICE
Date Employee last worked:___________________________ First full working day absent: ___________________
W/C claim filed: ____________________________________ Date return to work: __________________________
Remarks:_____________________________________________________________________________________
Received by: ___________________________________ Approved by: ___________________________________
Name and Date
Name and Date
518.477.8771
10 Empire State Blvd., Castleton, New York 12033
Fax: 518.477.9833
Revised: 12/1/2004
HR Forms

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