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Click ‘Get Form’ to open the PA 635 in the editor.
Begin by entering the client’s name, date of birth, phone number, and address in the designated fields at the top of the form.
In Section I, provide the medical provider's information including their printed name, medical license number, NPI number (if applicable), and contact details.
Confirm pregnancy status by filling in the expected delivery date if applicable. If pregnancy does not affect employability, only complete Section I.
In Section II, assess employability by selecting one of the options: Employable, Limited Employability, Temporary Incapacity, or Disabled. Fill in any required details based on your selection.
Complete Section III by listing all diagnoses along with their ICD-9 codes and descriptions. Explain how each diagnosis affects the client's ability to work.
Ensure that all sections are filled accurately and review for completeness before saving your changes.

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