Medical clearance request 2026

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4.8 out of 5

215 votes

The document is a Medical Clearance Request form for child care licensing in Michigan, intended to assess the physical and mental health of individuals applying to provide care for children. It includes sections for applicant information, patient details, authorization for medical information release, and medical evaluations by a physician to ensure the caregiver's suitability and safety in a child care setting.

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Click ‘Get Form’ to open the medical clearance request in the editor.
Begin by filling out the 'Applicant/Licensee Information' section. Enter the facility or home name, license number, and address details accurately.
In the 'Patient Information' section, provide your full name, date of birth, telephone number, and address. Ensure all information is printed clearly.
Complete the 'Release of Information' section by signing and dating it. This authorizes the release of your medical information for licensing purposes.
The physician will fill out the 'Medical Information' section. They need to answer questions regarding TB testing and provide comments on your physical and mental health condition.
Finally, ensure that both you and your physician sign and date where required before submitting the form as instructed.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (215 Votes)
2016	4 Satisfied (50 Votes)

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