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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the applicant/recipient's name and the worker's name in the designated fields. Ensure all information is accurate.
- In the 'Diagnosis' section, provide a detailed diagnosis of the applicant/recipient’s condition. Attach any necessary documentation to support your assessment.
- List all medications needed for the applicant/recipient to sustain employment based on their diagnosis. Be specific and thorough.
- Explain why the applicant/recipient cannot work without these medications. Include details about whether the condition is chronic or temporary.
- Fill in the medical provider's information, including their telephone number and address, ensuring legibility.
- Obtain signatures from both the physician and applicant/recipient, ensuring that they are original signatures as required.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.8 Satisfied (98 Votes) | |
| 2019 | 4.3 Satisfied (36 Votes) | |
| 2019 | 4.8 Satisfied (69 Votes) | |
| 2017 | 4.8 Satisfied (108 Votes) | |
| 2016 | 4.8 Satisfied (238 Votes) | |
| 2016 | 4.8 Satisfied (145 Votes) | |
| 2016 | 4.8 Satisfied (114 Votes) | |
| 2016 | 4.3 Satisfied (176 Votes) | |
| 2016 | 4.5 Satisfied (53 Votes) | |
| 2016 | 4.1 Satisfied (20 Votes) | |
| 2014 | 4.8 Satisfied (178 Votes) | |
| 2011 | 4.2 Satisfied (51 Votes) | |
| 2011 | 4.8 Satisfied (61 Votes) | |
| 2011 | 4.8 Satisfied (86 Votes) | |
| 2010 | 4.9 Satisfied (481 Votes) |
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