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Citgo duty medical form

Citgo duty medical form 2025

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The document outlines the procedures and requirements for CITGO Petroleum Corporation employees regarding fitness for duty certifications, medical disclosures, and return-to-work protocols. It includes sections for health care providers to assess an employee's ability to perform safety-sensitive job functions, authorization for the disclosure of protected health information, and instructions for both employees and supervisors on managing medical absences and transitional duties.

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Click ‘Get Form’ to open the citgo duty medical form in the editor.
Begin by filling in your personal details, including your name, personnel number, location, supervisor's name, job title, and supervisor's contact number.
Next, the health care provider should review and complete the section regarding the employee’s essential functions and provide a diagnosis if necessary.
Indicate whether the employee can perform their essential functions and specify any restrictions or medications required for their return to work.
Complete the authorization for disclosure section by providing your date of birth, phone number, social security number, and address. Ensure you sign and date this section.
Finally, follow the instructions for submission to CITGO Health Services via mail or fax as indicated on the form.

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