Employee-To-Employee Leave Donation Program Medical Request Form

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EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
MEDICAL REQUEST FORM
TO BE COMPLETED BY EMPLOYEE’S TREATING PHYSICIAN
PATIENT’S NAME: _________________________________________________________________
DIAGNOSIS(ES):
_________________________________________________________________
____________________________________________________________________________________
ICD CODE(S):
_____________
_____________
_____________
_____________
SUMMARY OF TREATMENT(S) & PROCEDURE(S): __________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
CPT CODE(S):
_____________
_____________
_____________
_____________
SURGERY DATE (IF APPLICABLE): ________________________________________________
HOSPITALIZATION DATE(S) (IF APPLICABLE): From: _____________ To: _____________
CAN EMPLOYEE WORK IN A MODIFIED CAPACITY?
YES_________
NO_________
IF YES, EXPLAIN RESTRICTIONS FOR MODIFIED DUTY:
__________________________________________________________________________
__________________________________________________________________________
DATE EMPLOYEE IS LIKELY TO RETURN TO:
MODIFIED DUTY: _________________________ FULL DUTY: ________________________
____________________________________________
____________________________________
PHYSICIAN’S SIGNATURE
PHYSICIAN’S NAME (PRINTED)
____________________________________________
____________________________________
PHYSICIAN’S PHONE NUMBER
DATE FORM COMPLETED
This document shall be treated as a confidential medical record; it shall not be placed in the
employee’s personnel file. Only those individuals with a need to know this information will be
given access to it. An employee who fails to appropriately safeguard the confidentiality of this
information will be subject to disciplinary action, including termination from State Service.
MS 402 E-to-E
(Revised September 2015)

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