Form PAY-23CF Physician's Certification for Catastrophic Leave Request - Immediate Family Member - Nevada

Form PAY-23CF is a Nevada Department of Administration form also known as the "Physician's Certification For Catastrophic Leave Request - Immediate Family Member". The latest edition of the form was released in January 1, 2016 and is available for digital filing.

Download an up-to-date Form PAY-23CF in PDF-format down below or look it up on the Nevada Department of Administration Forms website.

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Physician's Certification for Catastrophic Leave Request - Immediate Family Member
The State of Nevada's Catastrophic Leave program allows State employees to donate excess sick or annual leave to eligible co-workers
who have experienced a catastrophe and have exhausted their own paid leave balances. As per NAC 284.576, an appointing authority
may require the following form to be completed in order to substantiate the need for leave.
Section I (to be completed by the employee):
Employee name: _________________________________________________________ Employee ID#: _______________________
Patient name and relationship: ________________________________________________________________________________
Employee signature: ____________________________________________________ Date: ______________________________
Section II (to be completed by the attending health care provider):
1.
Describe the serious illness, accident or motor vehicle crash which supports the need for leave. If your patient experienced an
accident or motor vehicle crash, describe the medical conditions that resulted from that accident or motor vehicle crash.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
a.
If yes, what is the date the serious illness commenced or the accident or motor vehicle crash occurred?
__________________________________
2.
Is your patient's serious illness or medical condition "life threatening" resulting in a substantial risk of death?
No
Yes
a.
If yes, please explain. ________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3.
Does your patient have a serious illness or medical condition requiring a convalescence which you expect to exceed 10 consecutive
weeks?
No
Yes
a.
If yes, please explain.________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Estimate the beginning and ending dates for the period of needed care due to the patient’s incapacity:
4.
________________________________________________________________________________________________________
5.
Explain the care needed by the patient and why such care is medically necessary:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
6.
Will your patient need follow-up treatment following the period of incapacity (see question 4)?
No
Yes
a.
If yes, what is the nature of the follow-up treatment? _______________________________________________________
__________________________________________________________________________________________________
b.
If yes, how frequently will the follow-up treatment be required? ______________________________________________
c.
If yes, when do you expect your patient to complete his/her follow-up treatment (date or length of time):
__________________________________________________________________________________________________
Health care provider name: ___________________________________________________________________________________
Type of practice – field of specialty: _____________________________________________________________________________
Address: ___________________________________________________________________________________________________
____________________________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Signature of health care provider: ______________________________________________________________________________
Date: ______________________________________________________________________________________________________
PAY-23CF (Rev. 1/16)
Physician's Certification for Catastrophic Leave Request - Immediate Family Member
The State of Nevada's Catastrophic Leave program allows State employees to donate excess sick or annual leave to eligible co-workers
who have experienced a catastrophe and have exhausted their own paid leave balances. As per NAC 284.576, an appointing authority
may require the following form to be completed in order to substantiate the need for leave.
Section I (to be completed by the employee):
Employee name: _________________________________________________________ Employee ID#: _______________________
Patient name and relationship: ________________________________________________________________________________
Employee signature: ____________________________________________________ Date: ______________________________
Section II (to be completed by the attending health care provider):
1.
Describe the serious illness, accident or motor vehicle crash which supports the need for leave. If your patient experienced an
accident or motor vehicle crash, describe the medical conditions that resulted from that accident or motor vehicle crash.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
a.
If yes, what is the date the serious illness commenced or the accident or motor vehicle crash occurred?
__________________________________
2.
Is your patient's serious illness or medical condition "life threatening" resulting in a substantial risk of death?
No
Yes
a.
If yes, please explain. ________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3.
Does your patient have a serious illness or medical condition requiring a convalescence which you expect to exceed 10 consecutive
weeks?
No
Yes
a.
If yes, please explain.________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Estimate the beginning and ending dates for the period of needed care due to the patient’s incapacity:
4.
________________________________________________________________________________________________________
5.
Explain the care needed by the patient and why such care is medically necessary:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
6.
Will your patient need follow-up treatment following the period of incapacity (see question 4)?
No
Yes
a.
If yes, what is the nature of the follow-up treatment? _______________________________________________________
__________________________________________________________________________________________________
b.
If yes, how frequently will the follow-up treatment be required? ______________________________________________
c.
If yes, when do you expect your patient to complete his/her follow-up treatment (date or length of time):
__________________________________________________________________________________________________
Health care provider name: ___________________________________________________________________________________
Type of practice – field of specialty: _____________________________________________________________________________
Address: ___________________________________________________________________________________________________
____________________________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Signature of health care provider: ______________________________________________________________________________
Date: ______________________________________________________________________________________________________
PAY-23CF (Rev. 1/16)

Download Form PAY-23CF Physician's Certification for Catastrophic Leave Request - Immediate Family Member - Nevada

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