"Health Care Provider Certification Form" - City and County of San Francisco, California

"Health Care Provider Certification Form" - City and County of San Francisco, California Download Pdf
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Health Care Provider Certification Form is a legal document that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco.

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Date Received
HEALTH CARE PROVIDER CERTIFICATION FORM
_____________________________________
_______________________________
Employee's Name
Last 4 digits of Social Security No.
The above-referenced individual has identified you as the health care provider who is treating the
medical condition for which the individual is seeking reasonable accommodation. Attached is the
employee’s signed medical release. Please complete this certification form and the essential functions
guide and return it in the envelope provided. Please write legibly; if clarification is needed, you will be
contacted by a personnel representative. Thank you again for your assistance.
Date of your last examination of this individual: _______________
To discuss this matter, I am requesting that a department representative contact me by phone at:
A.
Major Life Activities
1.
Does this person have a medical condition, that makes one or more major
1
life activity/activities
difficult to perform?
Yes
No
2.
If yes, the major life activity/activities affected is/are: _______________
B.
Duration of Medical Condition
1.
Is this medical condition temporary? Yes ___
No ___
2.
If yes, please state the expected duration of this condition: ___________________
1
Major life activities include, but are not limited to, walking, talking, breathing, seeing, hearing, lifting, caring for oneself,
learning, thinking, concentrating, interacting with others, speaking, performing manual tasks, reading, sitting, and working.
Date Received
HEALTH CARE PROVIDER CERTIFICATION FORM
_____________________________________
_______________________________
Employee's Name
Last 4 digits of Social Security No.
The above-referenced individual has identified you as the health care provider who is treating the
medical condition for which the individual is seeking reasonable accommodation. Attached is the
employee’s signed medical release. Please complete this certification form and the essential functions
guide and return it in the envelope provided. Please write legibly; if clarification is needed, you will be
contacted by a personnel representative. Thank you again for your assistance.
Date of your last examination of this individual: _______________
To discuss this matter, I am requesting that a department representative contact me by phone at:
A.
Major Life Activities
1.
Does this person have a medical condition, that makes one or more major
1
life activity/activities
difficult to perform?
Yes
No
2.
If yes, the major life activity/activities affected is/are: _______________
B.
Duration of Medical Condition
1.
Is this medical condition temporary? Yes ___
No ___
2.
If yes, please state the expected duration of this condition: ___________________
1
Major life activities include, but are not limited to, walking, talking, breathing, seeing, hearing, lifting, caring for oneself,
learning, thinking, concentrating, interacting with others, speaking, performing manual tasks, reading, sitting, and working.
C.
Medical Restrictions
1.
Please list the medical restriction(s) that make the major life activity/activities
difficult to perform. Please be as specific as possible by listing duration and extent
of the restriction (e.g., cannot lift over 50 pounds; unable to stand for more than 1
hour; unable to walk for more than 1 block; unable to work more than 6 hours/day;
unable to perform multiple projects simultaneously):
D.
Reasonable Accommodation Request
1.
Please specify what type of accommodation you would recommend for this patient:
Purchase of Assistive Device(s):
Removal of Communications Barrier:
Purchase of Assistive Services:
Removal of Architectural Barrier:
Job Restructuring:
Modified Work Schedule:
Reassignment to Another Position:
Other:
2.
Does the employee's medical condition necessitate this proposed accommodation?
Yes
No
Explain:
3.
Does this proposed accommodation enable this patient to perform the essential functions
of the patient's position?
Yes
No
Explain:
ESSENTIAL FUNCTIONS GUIDE
For each essential function listed, please check if this person can perform that function, with or
without accommodation, or not at all.
If you indicate that an accommodation is needed, please specify the accommodation.
Name of Employee: ____________________________________
Class _________ Title _________________________ Department _____________________________
Work Shift, if applicable: ________________________________
General Description of Position:
Essential Function
Able to Perform
Able to Perform
Unable to Perform
without an
with an
with or without an
accommodation.
accommodation.
accommodation.
(Identify Below)
1.
2.
3.
4.
5.
6.
7.
8.
As to each essential function for which the individual seeks an accommodation, please identify your
recommended accommodation:
I, the undersigned health care provider, certify that the information I have provided regarding the
above-referenced individual is complete and accurate to the best of my knowledge. I understand
that my cooperation is necessary for the employer to make an accurate determination regarding
my patient's reasonable accommodation request.
____________________________________
____________________________________
Health Care Provider's Signature
Date
____________________________________
____________________________________
Print Name
License No.
____________________________________
____________________________________
Phone Number
Area of Practice
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