"Catastrophic Leave Program Physician's Certification" - Arkansas

Catastrophic Leave Program Physician's Certification is a legal document that was released by the Arkansas Department of Transformation and Shared Services - a government authority operating within Arkansas.

Form Details:

  • Released on May 27, 2021;
  • The latest edition currently provided by the Arkansas Department of Transformation and Shared Services;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Transformation and Shared Services.

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Department of Transformation and Shared Services
Office of Personnel Management
Catastrophic Leave Program Physician's Certification
Note: The employee and/or patient is responsible for the completion of this form at his or her own expense. All information listed on this form
will be kept confidential and is not to be released to or by the employer without written consent of the employee.
Name of Employee
(Last, First)
Address
(Street, City, State, Zip)
Name of Patient
(Last, First)
Authorization to Release Information: I hereby authorize the undersigned physician to release information acquired in the course of my
examination or treatment to my employer.My employer will provide his certification to the OPM Catastrophic Leave Bank Program for eligibility
determination purposed for short-term disability benefits. I understand that this authorization to disclose information will expire thirty (30) days
after the date of my signature or upon receipt by the physician of my written revocation, whichever comes first.
Employee's Signature
Date
(or Legal Representative)
Patient's Signature or Legal Representative
Date
(if Different than Employee)
To Be Completed by Patient's Physician
The following questions apply only to the conditions related to the patient's application for short-term disability benefits
from the State of Arkansas Catastrophic Leave Bank Program - Medical Emergency due to Illness/Injury
.
1. History
(a) When did patient first seek treatment for this illness/injury?
Date
(b) Could this illness/injury be work related?
Yes
No
(c) To your knowledge, has patient ever had the same or similar condition?
Yes
No
If "Yes," state when and describe:
2. Present Condition
(a) Is surgery:
Elective?
Required?
Date of Surgery:
When was the patient informed by the attending physician?
Date
(b) Is patient
?
Ambulatory
House Confined
Hospitalized
Bed Confined
(check one)
Page 1 of 2
OPM Catastrophic Leave Program Physician's Certification (Revised 05/27/2021)
Department of Transformation and Shared Services
Office of Personnel Management
Catastrophic Leave Program Physician's Certification
Note: The employee and/or patient is responsible for the completion of this form at his or her own expense. All information listed on this form
will be kept confidential and is not to be released to or by the employer without written consent of the employee.
Name of Employee
(Last, First)
Address
(Street, City, State, Zip)
Name of Patient
(Last, First)
Authorization to Release Information: I hereby authorize the undersigned physician to release information acquired in the course of my
examination or treatment to my employer.My employer will provide his certification to the OPM Catastrophic Leave Bank Program for eligibility
determination purposed for short-term disability benefits. I understand that this authorization to disclose information will expire thirty (30) days
after the date of my signature or upon receipt by the physician of my written revocation, whichever comes first.
Employee's Signature
Date
(or Legal Representative)
Patient's Signature or Legal Representative
Date
(if Different than Employee)
To Be Completed by Patient's Physician
The following questions apply only to the conditions related to the patient's application for short-term disability benefits
from the State of Arkansas Catastrophic Leave Bank Program - Medical Emergency due to Illness/Injury
.
1. History
(a) When did patient first seek treatment for this illness/injury?
Date
(b) Could this illness/injury be work related?
Yes
No
(c) To your knowledge, has patient ever had the same or similar condition?
Yes
No
If "Yes," state when and describe:
2. Present Condition
(a) Is surgery:
Elective?
Required?
Date of Surgery:
When was the patient informed by the attending physician?
Date
(b) Is patient
?
Ambulatory
House Confined
Hospitalized
Bed Confined
(check one)
Page 1 of 2
OPM Catastrophic Leave Program Physician's Certification (Revised 05/27/2021)
3. Diagnosis Give a COMPLETE narrative of the nature and extent of the present illness/injury which is creating the
need for short-term disability provided by the State's Catastrophic Leave Bank Program. Please be
specific. For example: Stating the employee/patient has skin cancer is not sufficient; further stating the cancer is
basal cell or melanoma is needed, or, stating the employee/patient requires or has had abdominal surgery is not
sufficient; further stating whether the surgery is/was laparoscopic or open surgery is needed.
4. Continuing Required Treatment for this Illness/Injury
(a) Projected Date of first office visit/treatment:
(b) Frequency of visits/treatments
Weekly
Monthly
Other
(c) When did you last examine patient?
(d) Give a brief description of the continuing treatments required by this illness/injury:
5. Prognosis and Anticipated Time Duration that Employee Will Be Unable To Work Due To The Health Condition of
Employee or Required Direct Care of a Family Member
(a) If there are no further complications, what is the minimum recovery time of the patient before the employee may return
to work?
Approximate Return Date:
(b) What is the maximum recovery time of the patient before the employee may return to work?
Approximate Return Date:
(c) If the patient is a State Employee, is there a possibility of working intermittent or reduced schedule or returning to work on a
part-time basis with job duties altered, within reason, to better fit his/her needs?
Yes
No
If yes, Approximate Return Date:
Please explain any limitations:
Clinic Name
Address
Telephone
Physician's Signature
Physician's Name (print)
Date
OPM Catastrophic Leave Program Physician's Certification (Revised 05/27/2021)
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