Form MS413 "Return to Work Medical Certification Form" - Maryland

What Is Form MS413?

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 February 1, 2013;
  • 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 MS413 by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

ADVERTISEMENT
ADVERTISEMENT

Download Form MS413 "Return to Work Medical Certification Form" - Maryland

Download PDF

Fill PDF online

Rate (4.5 / 5) 13 votes
STATE OF MARYLAND
FAMILY AND MEDICAL LEAVE
RETURN TO WORK MEDICAL CERTIFICATION FORM
(Type or Print)
PART I
EMPLOYEE INFORMATION
Name:
Title:
Department:
Date Leave Commenced:
Date of Return to Work:
______________________________ Date: ______________________
Employee's signature:
PART II TO BE COMPLETED BY EMPLOYEE'S HEALTH CARE PROVIDER
 I certify that on _______________ (date), I examined ______________________ (name of
employee), and on the basis of my examination, this employee is ready to return to work and is
able to perform the functions of his/her position.
Signed: ______________________________________________ Date: __________________
Health Care Provider's Name, Address, and Telephone Number:
PART III TO BE COMPLETED BY EMPLOYER
Employer Remarks:
This form should be delivered or mailed to:
________________________________________
________________________________________
________________________________________
MS 413
Rev.0213
STATE OF MARYLAND
FAMILY AND MEDICAL LEAVE
RETURN TO WORK MEDICAL CERTIFICATION FORM
(Type or Print)
PART I
EMPLOYEE INFORMATION
Name:
Title:
Department:
Date Leave Commenced:
Date of Return to Work:
______________________________ Date: ______________________
Employee's signature:
PART II TO BE COMPLETED BY EMPLOYEE'S HEALTH CARE PROVIDER
 I certify that on _______________ (date), I examined ______________________ (name of
employee), and on the basis of my examination, this employee is ready to return to work and is
able to perform the functions of his/her position.
Signed: ______________________________________________ Date: __________________
Health Care Provider's Name, Address, and Telephone Number:
PART III TO BE COMPLETED BY EMPLOYER
Employer Remarks:
This form should be delivered or mailed to:
________________________________________
________________________________________
________________________________________
MS 413
Rev.0213