Form UIB-188 "Medical Statement" - Colorado

This version of the form is not currently in use and is provided for reference only.
Download this version of Form UIB-188 for the current year.

What Is Form UIB-188?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2014;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form UIB-188 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form UIB-188 "Medical Statement" - Colorado

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Colorado Department of Labor and Employment
Unemployment Insurance Claimant Services
P.O. Box 400, Denver, CO 80201-0400
303-318-9000 (Denver-metro area) or 1-800-388-5515 (outside Denver-metro area)
Date
Social Security Number
XXX-XX-
Due Date
MEDICAL STATEMENT
By signing your name in Section 1, you authorize your physician or medical practitioner to provide information to the Unemployment Insurance (UI) Division.
Section 2 is to be completed by your physician. Complete and sign Section 3 only after your physician has completed Section 2. By signing your name in
this section, you are confirming that you understand the information provided by your physician. You are responsible for returning the form.
Section 1. Consent to Release Medical Information
I consent to release the requested information for the purposes of processing my claim for UI benefits with the understanding that the information is for use
in determining my eligibility and entitlement for UI benefits in accordance with the Colorado law.
Claimant Signature
Date
Section 2. (To be completed by physician or medical practitioner only)
The person named above applied for unemployment insurance benefits. Obtaining the information requested below will help the UI Division make a
determination of eligibility and entitlement. Any alteration must be initialed. Your cooperation in providing this information is appreciated. The
completed form must be returned to us by the patient.
Medical Condition (State in layperson terms.)
Dates of Treatment
From
To
Is the patient able to return to work?
Yes
No
If the patient is able to return to work:
On what date was the patient able to return to work? __________________________
Are there any restrictions that would keep the patient from returning to his or her usual occupation?
Yes
No
If Yes, please list the restrictions (e.g., lifting restrictions, part-time work only, light-duty work)
______________________________________________________________________________________________________________
If the patient is unable to return to work:
On approximately what date will the patient be able to return to work? _________________________
Additional Comments
Physician Address
Telephone Number
Physician Name
Signature
Date
Section 3.
I have read and understand the above statement provided by my physician.
Comments
Claimant Signature
Date
NOTE: Please be aware that according to Colorado law, you must be able to work, available to start work, and actively seeking work during each week in
which payment of benefits is requested. If you do not meet all of these requirements, we may not be able to pay you benefits.
UIB-188 (R 07/2014)
Colorado Department of Labor and Employment
Unemployment Insurance Claimant Services
P.O. Box 400, Denver, CO 80201-0400
303-318-9000 (Denver-metro area) or 1-800-388-5515 (outside Denver-metro area)
Date
Social Security Number
XXX-XX-
Due Date
MEDICAL STATEMENT
By signing your name in Section 1, you authorize your physician or medical practitioner to provide information to the Unemployment Insurance (UI) Division.
Section 2 is to be completed by your physician. Complete and sign Section 3 only after your physician has completed Section 2. By signing your name in
this section, you are confirming that you understand the information provided by your physician. You are responsible for returning the form.
Section 1. Consent to Release Medical Information
I consent to release the requested information for the purposes of processing my claim for UI benefits with the understanding that the information is for use
in determining my eligibility and entitlement for UI benefits in accordance with the Colorado law.
Claimant Signature
Date
Section 2. (To be completed by physician or medical practitioner only)
The person named above applied for unemployment insurance benefits. Obtaining the information requested below will help the UI Division make a
determination of eligibility and entitlement. Any alteration must be initialed. Your cooperation in providing this information is appreciated. The
completed form must be returned to us by the patient.
Medical Condition (State in layperson terms.)
Dates of Treatment
From
To
Is the patient able to return to work?
Yes
No
If the patient is able to return to work:
On what date was the patient able to return to work? __________________________
Are there any restrictions that would keep the patient from returning to his or her usual occupation?
Yes
No
If Yes, please list the restrictions (e.g., lifting restrictions, part-time work only, light-duty work)
______________________________________________________________________________________________________________
If the patient is unable to return to work:
On approximately what date will the patient be able to return to work? _________________________
Additional Comments
Physician Address
Telephone Number
Physician Name
Signature
Date
Section 3.
I have read and understand the above statement provided by my physician.
Comments
Claimant Signature
Date
NOTE: Please be aware that according to Colorado law, you must be able to work, available to start work, and actively seeking work during each week in
which payment of benefits is requested. If you do not meet all of these requirements, we may not be able to pay you benefits.
UIB-188 (R 07/2014)