Fillable Online CITY OF MADISON MEDICAL STATUS ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name and agency/work unit in the designated fields at the top of the form.
3. Fill in today’s date, next physician’s appointment date, and next therapy appointment date as required.
4. Provide the clinic or hospital name along with the date and time of injury/illness.
5. Select the appropriate treatment type: Initial Injury/Illness, Follow-Up Care, or Independent Evaluation. Indicate if the patient is discharged, able to return to full work, working, or unable to work.
6. Detail any medication restrictions and specify work limitations by checking relevant boxes and providing maximum weights where applicable.
7. Explain any additional restrictions in the provided section for clarity.
8. Finally, ensure that a provider's printed name and signature are included before submitting your completed form.

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