EMPLOYMENT VERIFICATION STATEMENT - Jackson Health System 2026

1. Click ‘Get Form’ to open the EMPLOYMENT VERIFICATION STATEMENT in the editor.
2. Begin by filling in your Medical Record Number (MR#) at the top of the form.
3. Indicate your employment status by checking the appropriate box: Self-Employed, Unemployed, or Never Employed. If self-employed, provide your name.
4. If you are unemployed, enter your last date of employment. If you have never been employed, check that option.
5. For those employed without income documentation, select the relevant options indicating what documents you will provide or explain why you cannot obtain them.
6. Describe your work and list your last four weeks of income in the designated fields.
7. Ensure all signatures are completed at the bottom of the form, including Patient/Representative and JHS Representative signatures.

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