Medical clearance request 2026

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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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What requires medical clearance?

Whether youre preparing for outpatient orthopedic surgery, a dental procedure under anesthesia, or elective care like cosmetic surgery, your care team will likely require a pre-operative evaluation. Medical clearance ensures your body is healthy enough to safely undergo anesthesia and surgery.

How do you get a medical clearance?

Obtain Physical Examination: Obtain a physical exam for you and any accompanying EFMs from a licensed provider (i.e., a Physician Assistant, Nurse Practitioner, Doctor of Medicine, or Doctor of Osteopathic Medicine), who must complete and sign the DS-1843 /DS-1622 forms.

How to get a medical clearance?

Answer: Medical Clearance Medical clearance should, optimally, be provided by your primary care physician. The goal is to obtain a thorough review of your health by a physician with whom you are familiar in order to assess your candidacy for surgery.

What is involved in a medical clearance?

A medical clearance usually consists of a doctor visit where your medical history is reviewed, a physical exam, and any needed testing is ordered. If you are cleared healthy enough to participate in the activity you desire, the doctor will provide the medical clearance necessary to move forward.

Who can provide a medical clearance?

Role of Anesthesiologists and Surgeons. Anesthesiologists and surgeons play a critical role in the medical clearance process, as they are responsible for evaluating the patients risk for anesthesia and surgery.

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What do I need for medical clearance?

A: Confirmation Receipt from Online Booking. One (1) Fully Accomplished BOQ PE Form 2: Medical Exam for Local Applicants (To be filled up at BOQ) 11 ID Picture with White Background (Three (3) pieces for New Application and Two (2) pieces for Renewal) Previous Health Card (For Renewal Only)

How long does a medical clearance take?

Basic Evaluations: Without tests, it may take up to 12 days. Comprehensive Clearances: If lab tests or imaging studies are required, may take several days.

What conditions need medical clearance?

When is medical clearance needed? The treatment of depression, PTSD, Anxiety, Bi-polar disorder, Anger management and other mental disorders. All heart related conditions, such as having a heart attack, having heart surgeries or a stent, an irregular heart rate, a valve problem in your heart, having a blood clot.