Honorhealth Leave Of Absence Request Form For Medical, Maternity, Family Or Military Page 3

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Medical Certification
Instructions
The attending physician must complete this form. This form has been designed to be used for a staff member’s absence
from work when the staff member’s own serious health condition makes him/her unable to perform his/her job. Intermittent
absence and reduced schedule requires Certification of Serious Health Condition.
The HonorHealth staff member must be under the regular care of a physician who certifies that the staff member is
disabled. The term physician means a person (other than you, your spouse, child, brother, sister or parent, or the child,
brother, sister or parent of your spouse) who is properly licensed as a M.D., D.O., D.P.M., D.D.S., D.M.D, or Psychiatrist,
and recognized by the state in which treatment is provided, and who is qualified to treat the condition or injury for which
you are applying for benefits. Chiropractors and Acupuncturists are not covered.
Patient Information
Name (printed)
Date of Birth
Social Security #
Address
City
State
Zip
Phone
Physician Information
Physician Name
Specialty
Address
City
State
Zip
Phone
Fax
Treatment Information
Is injury/illness work related?
Yes
No
Date Condition Began
Most Recent Treatment Date
Next Appointment Date
Date of Surgery
Date of Inpatient Hospitalization
Pregnancy Due Date
Primary Diagnosis
Subjective/Objective Findings
Treatment Plan (including type of surgery, prescribed medications, etc)
Work Status
Off work beginning _____________________ (date), ending ___________________________ (date)
Restricted work beginning _____________________ date, ending ___________________________ (date)
Restrictions
Limit shift to ____________ hours
No reaching above shoulder level
Limited use of ____________________
No lifting over ___________lbs
No kneeling or squatting
No use of ________________________
No push/pull over _______ lbs of force
No climbing stairs or ladders
No bending of _____________________
Should be sitting __________% of time
Other __________________________________________________________
Return to work with no restrictions, effective _________________________ (date)
Physician Signature
Date
X
Mail or fax completed documents to:
HonorHealth, Disability Management
8125 N Hayden Rd, Scottsdale, AZ 85258-5199
Phone: (480) 323-4540, Fax: (480) 882-5802
Rev January 2013- Medical, Family, Military

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