Form ADM4261 "Physician or Health Care Provider Certification for Living Organ and Bone Marrow Donor Leave" - Ohio

What Is Form ADM4261?

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

Form Details:

  • The latest edition provided by the Ohio Department of Administrative Services;
  • 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 ADM4261 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form ADM4261 "Physician or Health Care Provider Certification for Living Organ and Bone Marrow Donor Leave" - Ohio

252 times
Rate (4.3 / 5) 15 votes
STATE OF OHIO
PHYSICIAN OR HEALTH CARE PROVIDER CERTIFICATION
FOR LIVING ORGAN AND BONE MARROW DONOR LEAVE
(Please Print)
Employee's Name (First/Middle/Last)
Social Security Number
___________________________________________________________________________________
Employee's Job Title
Agency & Employee Location
___________________________________________________________________________________
Home Address
Street
City/State
Zip
___________________________________________________________________________________
Telephone Home / Work
( )
( )
1. This information is being provided by:
a) Physician ‫ ڤ‬Yes ‫ ڤ‬No
b) Practitioner ‫ ڤ‬Yes ‫ ڤ‬No
c) Another provider of health services ‫ ڤ‬Yes ‫ ڤ‬No.
2. Information of Physician or other health services provider who performed the procedure:
Name
Address
Street
City/State
Zip
__________________________________________________________________________________________
3. Date the procedure commenced: _______________________.
4. Where the procedure commenced:
Facility Name
Address
Street
City/State
Zip
__________________________________________________________________________________________
5. Type of procedure: ‫ ڤ‬Kidney or Liver Donation ‫ ڤ‬Bone Marrow Donation
I certify that the information contained in this form is true to the best of my knowledge.
__________________________________________________________
Date
Attending Physician's / Health Care Provider's Signature
I voluntarily authorize the State of Ohio to contact my Health Care Provider for clarification of the
information contained in this certification. Employee’s Initials: _____________
I certify that the information contained in this form is true to the best of my knowledge and understand
any misrepresentation on my part may result in denial of leave and/or discipline.
_________________________________________________________
Date
Employee's Signature
ADM 4261
STATE OF OHIO
PHYSICIAN OR HEALTH CARE PROVIDER CERTIFICATION
FOR LIVING ORGAN AND BONE MARROW DONOR LEAVE
(Please Print)
Employee's Name (First/Middle/Last)
Social Security Number
___________________________________________________________________________________
Employee's Job Title
Agency & Employee Location
___________________________________________________________________________________
Home Address
Street
City/State
Zip
___________________________________________________________________________________
Telephone Home / Work
( )
( )
1. This information is being provided by:
a) Physician ‫ ڤ‬Yes ‫ ڤ‬No
b) Practitioner ‫ ڤ‬Yes ‫ ڤ‬No
c) Another provider of health services ‫ ڤ‬Yes ‫ ڤ‬No.
2. Information of Physician or other health services provider who performed the procedure:
Name
Address
Street
City/State
Zip
__________________________________________________________________________________________
3. Date the procedure commenced: _______________________.
4. Where the procedure commenced:
Facility Name
Address
Street
City/State
Zip
__________________________________________________________________________________________
5. Type of procedure: ‫ ڤ‬Kidney or Liver Donation ‫ ڤ‬Bone Marrow Donation
I certify that the information contained in this form is true to the best of my knowledge.
__________________________________________________________
Date
Attending Physician's / Health Care Provider's Signature
I voluntarily authorize the State of Ohio to contact my Health Care Provider for clarification of the
information contained in this certification. Employee’s Initials: _____________
I certify that the information contained in this form is true to the best of my knowledge and understand
any misrepresentation on my part may result in denial of leave and/or discipline.
_________________________________________________________
Date
Employee's Signature
ADM 4261