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Section I - Medical Provider Information

Section I - Medical Provider Information 2025

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The document is an Employee Medical Statement form used by the Office of Early Learning and School Readiness in Ohio, which complies with Ohio Administrative Code. It requires medical provider information, employee medical status certification regarding communicable diseases, and details any medical limitations. The form must be completed by qualified medical professionals and updated regularly as per program policy. Itinerant teachers and related service personnel must provide documentation every three years.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Physician/Clinic/Hospital Name in the designated field. This identifies the medical provider responsible for the employee's health assessment.
Next, fill in the Provider Address. Ensure that you include all relevant details such as street address, city, state, and zip code to maintain accurate records.
Input the Provider Phone Number. This is crucial for any follow-up communication regarding the medical statement.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (50 Votes)
2018	4 Satisfied (54 Votes)
2016	4.3 Satisfied (57 Votes)
2010	4.7 Satisfied (52 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the DOL provider number?

How do I find my department of labor number?

0:16 1:55 Now if youre an employee trying to find your employers do number you can check your W2. Form itsMoreNow if youre an employee trying to find your employers do number you can check your W2. Form its usually located in box B. If youre a former employee.

What is a state provider number?

This identifier is a six-digit number. The first two digits specify the state in which the provider is located, and the last four digits indicate the type of facility. For ambulatory surgery centers, the MPN is 10 digits with the first two digits representing the state where the surgery center is located.

Who is considered my medical provider?

A licensed person or organization that provides health care services. Examples of health care providers include doctors, nurses, therapists, pharmacists, laboratories, hospitals, clinics, and other health care centers. Definition of health care provider - NCI Dictionary of Cancer Terms National Cancer Institute dictionaries cancer-terms def National Cancer Institute dictionaries cancer-terms def

What is DOL in medical billing?

The Department of Labor (DOL) billing office handles all medical bills pertaining to your workplace injury or illness. Most major hospitals have an online account with DOL where they can submit bills.

What is a provider in medical insurance?

Providers can include doctors, psychologists, or physical therapists, and health care facilities, like hospitals, urgent care clinics, or pharmacies. Insurance companies may have different networks for different plans, so make sure you search the provider network of each specific plan you compare. What You Should Know About Provider Networks - CMS CMS outdocHub-and-education what-y CMS outdocHub-and-education what-y

What is a DOL provider number?

A US Department of Labor number is a unique provider identification number used for claim submission required by the health plans. Typically this number is used during the processing of workers compensation claims. Refer to the US Department of Labor at for information on obtaining this number. What is a US Department of Labor Number? Practice Fusion Knowledge Base article what-is-a-us-de Practice Fusion Knowledge Base article what-is-a-us-de

Section I - Medical Provider Information 2025

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