Nucs 4194 form-2026

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The document is a Medical Statement form from the Department of Employment, Training and Rehabilitation's Employment Security Division. It is intended for claimants to have their physicians complete necessary medical information to determine eligibility for unemployment benefits. The form requests details about the claimant's medical condition, treatment dates, work limitations, and any advice given by the physician regarding employment due to health issues.

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Click ‘Get Form’ to open the nucs 4194 form in the editor.
Begin by entering the date and your Social Security Number (SSN) at the top of the form. This information is crucial for processing your claim.
Provide your physician's name and ensure they complete all fields regarding your medical condition, including dates of care and nature of illness.
Answer the questions regarding hospitalization and any advice given by your physician about quitting your job for health reasons. Be sure to check 'Yes' or 'No' as applicable.
If applicable, provide details on any work limitations or expected delivery dates if you are under care due to pregnancy.
Finally, ensure that your physician signs the form and includes their printed name, address, and phone number before submission.

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