Medical Release Form - Updated - Superior Court Of Santa Cruz County (Page 2 of 2) in pdf

Medical Release Form - Updated - Superior Court Of Santa Cruz County Page 2

M 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 III: PHYSICIAN OR LICENSED/CERTIFIED PSYCHOLOGIST STATEMENT

Continued

3. If the patient is currently unable to work or participate in a training program, please indicate when

the patient is expected to be released to work or training: ___/___/___

4. Please list the diagnosis and prognosis for this patient: _________________________________

_____________________________________________________________________________

5. Other comments: _______________________________________________________________

_____________________________________________________________________________

6. Date of Last Examination: ___/___/___

Next Appointment: ___/___/___

SECTION IV: PHYSICIAN OR PSYCHOLOGIST CERTIFICATION

I understand that statements I have made on this form are subject to verification and

investigation.

I declare under penalty of perjury under the laws of the United States and the State of

California that the information contained on this form is true, correct and complete.

Signature of Physician, Psychologist, or Person Authorized to Complete this Form

Date

Address of Office/Clinic:

Phone:

01.13.11

SC DCSS:S/P n T/Legal/Medical Release Form

Medical Release Form - Updated - Superior Court Of Santa Cruz County Page 2