Fillable Cat-leave-physician-certification-form 12-07-17 CITY OF LITTLE ROCK

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Cat-leave-physician-certification-form 12-07-17 CITY OF LITTLE ROCK

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Revised 12-07-17
CITY OF LITTLE ROCK – CATASTROPHIC LEAVE REQUEST
PHYSICIAN CERTIFICATION FORM
Return completed form to Fax (501) 371-4496, Attention: Labor & Employee Relations Division
Please call (501) 371-4575 if you have any questions regarding completion of this form.
EMPLOYEE NAME: _________________________________________________________
DATE EMPLOYEE WILL EXHAUST PAID LEAVE BALANCES: _____________________
Authorization to Release Information: I hereby authorize the undersigned physician to release information acquired in
the course of my examination or treatment to the City of Little Rock’s Catastrophic Leave Bank Committee for eligibility
determination for short-term salary continuation. I understand that this authorization to disclose information will expire
thirty (30) days after the date of my signature or upon receipt by the physician of my written revocation, whichever comes
first.
________________________________________________________ ________________________
Employee Signature (or Legal Representative’s Signature*) Date
________________________________________________________ ________________________
*Printed Name of Employee’s Legal Representative Relation to Employee
TO BE COMPLETED BY PATIENT’S PHYSICIAN
1) HISTORY:
a) When did the patient first seek treatment for this illness/injury/condition? ____________________
2) DIAGNOSIS:
a) Provide a brief narrative of the nature and extent of the present injury/illness/condition which is
creating the need for short-term salary continuation provided by the City of Little Rock’s Catastrophic
Leave Bank Program:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3) REQUIRED TREATMENT FOR THIS ILLNESS/INJURY/CONDITION:
a) When did you last examine the patient for this illness/injury/condition? ______________________
b) Give a brief description of the frequency of continuing treatments required by this condition:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Revised 12-07-17
4) PROGNOSIS AND ANTICIPATED TIME DURATION THAT EMPLOYEE WILL BE
UNABLE TO WORK DUE TO THE HEALTH CONDITION:
a) If there are no further complications, what is the minimum recovery time before the employee may
return to work?
Approximate Return to Work Date: ______________________________________
b) What is the maximum recovery time of the patient before the employee may return to work?
Approximate Return to Work Date: ______________________________________
c) Is there a possibility of returning to work on an intermittent or reduced schedule? □ Yes □ No
If yes, please explain when the employee might return to work on a modified schedule and specify any
limitations or reasonable accommodations the employee may need:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
This medical certification will be used by the City of Little Rock’s Catastrophic Leave Bank
Committee to determine if the employee meets the eligibility criteria for a short-term salary
continuation after exhausting leave benefits due to this illness/injury/condition. If the duration of this
medical condition continues beyond thirty (30) days, your patient will need you to complete this form
again to request additional Catastrophic Leave benefits.
_______________________________________________ _________________________
Clinic Name Clinic Phone Number
________________________________________________________________________________
Clinic Address
_______________________________________________
Printed Name of Physician
_______________________________________________ ________________________
Signature of Physician Date
Note: The employee is responsible for the completion of this form at his own expense. All
information listed on this form will be kept confidential and will not be released by the City of Little
Rock without written consent of the employee or the employee’s legal representative.
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Cat-leave-physician-certification-form 12-07-17 CITY OF LITTLE ROCK

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Completed 20 March 2020

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