Physician Certification Form - Illinois Department of Public Health 2025

1. Click ‘Get Form’ to open the Physician Certification Form in the editor.
2. Begin by filling out the 'Qualifying Patient Information' section. Enter the patient's first name, middle name, last name, home address, city, state (IL), ZIP code, date of birth, and gender.
3. Next, complete the 'Physician Information' section. Provide your first name, middle name, last name, office address, telephone number, email address, Illinois Physician License Number, and Controlled Substances License Number.
4. Indicate how long the patient has been under your care and the date of their in-person medical examination related to this certification.
5. In the 'Debilitating Medical Condition' section, check all applicable conditions that apply to the patient. Ensure you indicate any underlying chronic or debilitating condition.
6. Finally, review and sign the attestation section. Ensure your signature is handwritten as stamps are not accepted. Include the date of your signature.

Start using our platform today for free to streamline your document editing and signing process!