Medical Release Form - Updated - Superior Court Of Santa Cruz County
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1
2M E D I C A L R E L E A S E F O R M
For use by
COUNTY OF SANTA CRUZ
DEPARTMENT OF CHILD SUPPORT SERVICES
P.O. BOX 1841, SANTA CRUZ, CA 95061
(866) 901-3212 Fax: (831) 454-3752
SECTION I: PATIENT/CLIENT INFORMATION AND MEDICAL RELEASE
DCSS CASE #:
SUPERIOR COURT CASE #:
NAME OF PATIENT:
BIRTHDATE:
Last,
First
MI
SOCIAL SECURITY #:
I authorize
or
Name of Physician or Psychologist
Name of Clinic or Medical Group
to release any medical information on this form to the Santa Cruz County Department of Child
Support Services. This authorization is valid for one year from the date of signature.
Patient Signature
Date
SECTION II: PHYSICIAN OR LICENSED/CERTIFIED PSYCHOLOGIST INSTRUCTIONS
The above-named person has a medical condition that prevents or limits participation in work activities.
Participation activities may include full time or part time employment, job training, or other related
activities.
Please provide the following information about the patient’s medical condition, limitations,
and any other accommodations needed for the patient to engage in activities that will improve his/her
employability. If you need additional space, please use another sheet of paper and attach it to this form.
PLEASE COMPLETE AND RETURN THIS FORM IN THE ATTACHED ENVELOPE TO:
Santa Cruz County
Department of Child Support Services
PO Box 1841
Santa Cruz, CA 95061
SECTION III: PHYSICIAN OR LICENSED/CERTIFIED PSYCHOLOGIST STATEMENT
1.
Please indicate if the patient is able to:
Work full time with no limitations
Work full time with limitations
Explain: __________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Work part time up to ______ hours per day. Date patient may return to full time ___/___/___
Participate in a job training program. Please list any limitations:_______________________
__________________________________________________________________________
2. Please list any accomodations needed for the patient to work or participate in a training program:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
01.13.11
SC DCSS:S/P n T/Legal/Medical Release Form
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