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Form pa 635 2009-2026
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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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