Form K-BEN312 "Health Care Provider's Certification" - Kansas

What Is Form K-BEN312?

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

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Kansas Department of Labor;
  • 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 fillable version of Form K-BEN312 by clicking the link below or browse more documents and templates provided by the Kansas Department of Labor.

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Download Form K-BEN312 "Health Care Provider's Certification" - Kansas

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KANSAS DEPARTMENT OF LABOR
MAIL:
Unemployment Contact Center
www.dol.ks.gov
P.O. Box 3539
HEALTH CARE PROVIDER’S CERTIFICATION
Topeka, KS 66601-3539
FAX:
(785) 296-3249
K-BEN 312 Web (Rev. 10-17)
Submit
EMAIL*:
Claimant name: _____________________________________________ Social Security number: ______________________
Health care information is required to determine if you are eligible for unemployment insurance benefits. Take this form to your
health care provider for completion and then sign the certification. Return this form within seven days of the date you filed
your claim. Failure to reply by this date may result in a denial of benefits or possible overpayment.
PATIENT INFORMATION:
This individual has recently consulted you regarding a medical condition. The following information is required
for determination of the individual’s eligibility for unemployment insurance benefits.
Information provided for:
c Claimant
c Claimant’s family member
Relationship to claimant: ______________________________
Did you advise claimant to leave work?
c YES
c NO
If YES: c Permanent date advised (mm/dd/yyyy): __________________
c Temporary date advised (mm/dd/yyyy): __________________ Expected release to work date (mm/dd/yyyy): _______________
Individual was examined or treated for a medical condition from (mm/dd/yyyy): _______________________ to _______________________
Describe the medical condition in lay terms. Include the prognosis and advice given (i.e., change of climate, surgery, additional treatment,
hospitalization, etc.). Attach supporting documents, if applicable.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
c Became unable to work on (mm/dd/yyyy): ___________________
Is claimant able to continue employment in customary occupation?
c YES
c NO
c Was able to return to full-time work on (mm/dd/yyyy): _____________________
c Unknown at this time
Able to perform full-time work in another occupation?
c YES
c NO
If YES, date able to return to work: ______________________
Type of work: ___________________________________________________________________________________________________
Restrictions pertaining to full-time employment?
c YES
c NO
Restrictions: _____________________________________________________________________________________________________
HEALTH CARE PROVIDER INFORMATION:
Health Care Provider signature: _______________________________________________ Date (mm/dd/yyyy): ______________________
(
)
Printed name: _____________________________________________________________________ Phone: _______________________
Address: _________________________________________________________________________________________________
CLAIMANT’S RELEASE:
I herewith consent to the release of the above information to the Kansas Department of Labor with the
understanding that it is for confidential use by the Department in determining my eligibility for unemployment insurance benefits.
Claimant’s signature: ______________________________________________________ Date (mm/dd/yyyy): _______________________
*See important Email Notice on website.
KANSAS UNEMPLOYMENT CONTACT CENTER
Kansas City Area (913) 596-3500 • Topeka Area (785) 575-1460 • Wichita Area (316) 383-9947 • All Other Areas (800) 292-6333
KANSAS DEPARTMENT OF LABOR
MAIL:
Unemployment Contact Center
www.dol.ks.gov
P.O. Box 3539
HEALTH CARE PROVIDER’S CERTIFICATION
Topeka, KS 66601-3539
FAX:
(785) 296-3249
K-BEN 312 Web (Rev. 10-17)
Submit
EMAIL*:
Claimant name: _____________________________________________ Social Security number: ______________________
Health care information is required to determine if you are eligible for unemployment insurance benefits. Take this form to your
health care provider for completion and then sign the certification. Return this form within seven days of the date you filed
your claim. Failure to reply by this date may result in a denial of benefits or possible overpayment.
PATIENT INFORMATION:
This individual has recently consulted you regarding a medical condition. The following information is required
for determination of the individual’s eligibility for unemployment insurance benefits.
Information provided for:
c Claimant
c Claimant’s family member
Relationship to claimant: ______________________________
Did you advise claimant to leave work?
c YES
c NO
If YES: c Permanent date advised (mm/dd/yyyy): __________________
c Temporary date advised (mm/dd/yyyy): __________________ Expected release to work date (mm/dd/yyyy): _______________
Individual was examined or treated for a medical condition from (mm/dd/yyyy): _______________________ to _______________________
Describe the medical condition in lay terms. Include the prognosis and advice given (i.e., change of climate, surgery, additional treatment,
hospitalization, etc.). Attach supporting documents, if applicable.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
c Became unable to work on (mm/dd/yyyy): ___________________
Is claimant able to continue employment in customary occupation?
c YES
c NO
c Was able to return to full-time work on (mm/dd/yyyy): _____________________
c Unknown at this time
Able to perform full-time work in another occupation?
c YES
c NO
If YES, date able to return to work: ______________________
Type of work: ___________________________________________________________________________________________________
Restrictions pertaining to full-time employment?
c YES
c NO
Restrictions: _____________________________________________________________________________________________________
HEALTH CARE PROVIDER INFORMATION:
Health Care Provider signature: _______________________________________________ Date (mm/dd/yyyy): ______________________
(
)
Printed name: _____________________________________________________________________ Phone: _______________________
Address: _________________________________________________________________________________________________
CLAIMANT’S RELEASE:
I herewith consent to the release of the above information to the Kansas Department of Labor with the
understanding that it is for confidential use by the Department in determining my eligibility for unemployment insurance benefits.
Claimant’s signature: ______________________________________________________ Date (mm/dd/yyyy): _______________________
*See important Email Notice on website.
KANSAS UNEMPLOYMENT CONTACT CENTER
Kansas City Area (913) 596-3500 • Topeka Area (785) 575-1460 • Wichita Area (316) 383-9947 • All Other Areas (800) 292-6333