Form MS402-EE "Medical Certification Form" - Maryland

What Is Form MS402-EE?

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

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Maryland Department of Budget and Management;
  • 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 MS402-EE by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Download Form MS402-EE "Medical Certification Form" - Maryland

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STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY TREATING PHYSICIAN
EMPLOYEE’S NAME:
PATIENT’S NAME
:
(if not employee)
DIAGNOSIS(ES):
ICD 10 CODE(S):
SUMMARY OF TREATMENT(S) & PROCEDURE(S):
START DATE OF CURRENT INCAPACITY:
SURGERY DATE (IF APPLICABLE):
HOSPITALIZATION DATE(S) (IF APPLICABLE): FROM:
TO:
CAN EMPLOYEE WORK IN A MODIFIED CAPACITY? YES:
NO:
IF YES, PROVIDE RESTRICTIONS FOR MODIFIED DUTY:
__________________________________________________________________________
PROVIDE DATE EMPLOYEE IS LIKELY TO RETURN TO:
MODIFIED DUTY: __________________________
FULL DUTY: _______________________
____________________________________________
____________________________________
PHYSICIAN’S NAME (PRINTED)
PHYSICIAN’S PHONE NUMBER
____________________________________________
____________________________________
PHYSICIAN’S SIGNATURE
DATE FORM COMPLETED
(PLEASE ATTACH MEDICAL VERIFICATION OF SURGERY OR BIRTH;
TYPE OF BIRTH IS REQUIRED)
Failure to provide sufficient medical documentation may delay the processing of this request. This
information 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-EE
(Rev. 4/2018)
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY TREATING PHYSICIAN
EMPLOYEE’S NAME:
PATIENT’S NAME
:
(if not employee)
DIAGNOSIS(ES):
ICD 10 CODE(S):
SUMMARY OF TREATMENT(S) & PROCEDURE(S):
START DATE OF CURRENT INCAPACITY:
SURGERY DATE (IF APPLICABLE):
HOSPITALIZATION DATE(S) (IF APPLICABLE): FROM:
TO:
CAN EMPLOYEE WORK IN A MODIFIED CAPACITY? YES:
NO:
IF YES, PROVIDE RESTRICTIONS FOR MODIFIED DUTY:
__________________________________________________________________________
PROVIDE DATE EMPLOYEE IS LIKELY TO RETURN TO:
MODIFIED DUTY: __________________________
FULL DUTY: _______________________
____________________________________________
____________________________________
PHYSICIAN’S NAME (PRINTED)
PHYSICIAN’S PHONE NUMBER
____________________________________________
____________________________________
PHYSICIAN’S SIGNATURE
DATE FORM COMPLETED
(PLEASE ATTACH MEDICAL VERIFICATION OF SURGERY OR BIRTH;
TYPE OF BIRTH IS REQUIRED)
Failure to provide sufficient medical documentation may delay the processing of this request. This
information 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-EE
(Rev. 4/2018)