Form pa 1671 2005-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the applicant/recipient's name and the worker's name in the designated fields. Ensure all information is accurate.
3. In the 'Diagnosis' section, provide a detailed diagnosis of the applicant/recipient’s condition. Attach any necessary documentation to support your assessment.
4. List all medications needed for the applicant/recipient to sustain employment based on their diagnosis. Be specific and thorough.
5. Explain why the applicant/recipient cannot work without these medications. Include details about whether the condition is chronic or temporary.
6. Fill in the medical provider's information, including their telephone number and address, ensuring legibility.
7. Obtain signatures from both the physician and applicant/recipient, ensuring that they are original signatures as required.

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