Form Ix-3 - Fitness-For-Duty Certification - Commonwealth Of Massachusetts Page 2
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2Health Care Provider Remarks:
_____
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________
_____________________________
Signature of Health Care Provider
Date
________________________________________
Name of Health Care Provider (typed or printed)
_________________________________________________________________________________
Address
Telephone
Area of Practice/Specialty (if any):
Please return this form to
___________
FOR OFFICE USE ONLY
Confirm Return Date:
Notified Payroll On:
Initials:
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