Form MS402-LB "Leave Bank Medical Certification Form" - Maryland

Form MS402-LB is a Maryland Department of Budget and Management form also known as the "Leave Bank Medical Certification Form". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download a PDF version of the Form MS402-LB down below or find it on Maryland Department of Budget and Management Forms website.

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Download Form MS402-LB "Leave Bank Medical Certification Form" - Maryland

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STATE EMPLOYEES’ LEAVE BANK REQUEST
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY EMPLOYEE’S TREATING PHYSICIAN
PATIENT’S NAME: _________________________________________________________________
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:
__________________________________________________________________________
__________________________________________________________________________
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-LB
(Rev. 4/2018)
STATE EMPLOYEES’ LEAVE BANK REQUEST
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY EMPLOYEE’S TREATING PHYSICIAN
PATIENT’S NAME: _________________________________________________________________
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:
__________________________________________________________________________
__________________________________________________________________________
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-LB
(Rev. 4/2018)
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