Fill and Sign the When Can My Employer Ask Me for Medical Information or a

Doctor’s Assessment Form Page 1 of 3Basic form © James R. McDade (ver 05-24-06) 209-667-2300 DOCTOR'S ASSESSMENT OF MEDICAL ABILITY TO PERFORM JOB Note: Employers use this form to determine if the employee or job applicant is medically able to do the job. As with all forms, some modification may be needed to fit the circumstances. Seek legal counsel were appropriate. (Delete this note prior to use.)Employee/Applicant’s Name: __________________________________ Date: ______________________Employer’s Name: __________________________________________Dear Doctor:We are trying to determine if the employee/applicant (hereinafter referred to as “patient”) can perform the job as described on the attached job description without further injury to the patient or others or undue pain to the patient. [Option, if applicable> The patient has told us, or we have observed, the following symptoms, complaints, or conditions which you may not be aware of: ___________________________________________________________ ___________________________________________________________________________________________Please give your medical opinion to the questions below, taking into consideration the physical nature of the job, the environmental conditions under which the job must be performed, and emotional requirements of the job. Please see the attached release from the patient authorizing you to provide the requested information.  TO BE COMPLETED BY PATIENT’S DOCTOR  1.Does the patient have a medical condition that is affecting the patient’s ability to work?  Yes  No2. Is the patient’s medical condition likely to resolve within 8 weeks or less?  Yes  No  Not Applicable3.Can the patient return to work?  No, the patient must be totally off work from _______________, 20___ to _______________, 20___. Yes, the patient can return to work with restrictions as described below starting on ______________, 20___. Yes, the patient can return to work without restrictions starting on _______________, 20___. 4.If the patient can work, but needs time off for medical reasons, including treatment, please describe the time off needed: Patient is limited to working: ____ hours per day ____ hours per week ____ days per week This time restriction is  permanent  temporary until _______________, 20___. Patient needs time off for treatment as follows: _______________________________________________Other restrictions or comments: ___________________________________________________________ 5.[Option>If the patient is released to return to work, please evaluate whether the patient is able to perform all the job duties listed in the attached job description without there being a “direct threat” of injury to the patient or others. Please note that the ADA defines “direct threat” (whether to the patient or others) as a specific and significant risk of substantial harm that is not speculative or remote and that is based on objective medical evidence regarding the patient. Under the FEHA, direct threat means that the risk of injury to the patient is “imminent and substantial;'' and the risk to others must be no greater than if an individual without a disability performed the job. The regulations suggest that a direct threat be evaluated based on the severity, probability, imminence, and duration of the risk. Please take into consideration any medications that the patient would use.The patient can return to work without a “direct threat” of injury to him/herself or others, but with the following listed job restrictions: Doctor’s Assessment Form Page 2 of 3Basic form © James R. McDade (ver 05-24-06) 209-667-2300 a. Job restriction: ________________________________________________________________________ Possible accommodation, if any: ___________________________________________________________Restriction is  Permanent  Temporary from ________________, 20___ to ________________, 20___ b.Job restriction: ________________________________________________________________________ Possible accommodation, if any: ____________________________________________________________Restriction is  Permanent  Temporary from ________________, 20___ to ________________, 20___ c.Job restriction: ________________________________________________________________________ Possible accommodation, if any: ____________________________________________________________Restriction is  Permanent  Temporary from ________________, 20___ to ________________, 20___ 6.In your opinion, the patient’s medical condition is the result of which of the following? (Mark each box that is applicable.)  Work related injury or illness at CURRENT job  Work related injury or illness at a PRIOR job Non-work related injury or illness or condition  Pregnancy related condition 7. Will the patient's medical condition likely improve with future treatment?  Yes  No8.Is the patient’s medical condition permanent and stationary?  Yes  No9.When is the patient's next doctor's appointment with your office? ____________________________10.List any other information you deem important regarding the patient’s ability or inability to perform the job or need for an accommodation:__________________________________________________________________________________________ ________________________________________________________________________________________ __________________________________________________________________________________ Signature of treating Physician: Dr. _________________________________ Date: _____________________ Please return this form to the employer at:Name: ______________________________Phone: _____________________________ Fax: ________________________________ Doctor’s Assessment Form Page 3 of 3Basic form © James R. McDade (ver 05-24-06) 209-667-2300 AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION This authorization for disclosure of medical information is being given in compliance with the Confidentiality of Medical Information Act of 1981 (California Civil Code §56) and the federal HIPAA.I, ___________________________________, hereby authorize _______________________________________ [name of employee or applicant] [name of physician, hospital, or testing center] to furnish to _____________________________________________________ (hereinafter “Company”) [name of employer] the results and protected health information pertaining to the following marked tests and examinations: Alcohol Test Post-Offer, Pre-Employment Physical Examination Drug Test Doctor’s Assessment of Medical Ability to Perform JobOther (explain): _____________________________________________________________ I authorize that the Company to ask questions about the above marked tests and examinations and to use my protected health information provided in response to this authorization to determine the following marked issues:Whether, as a job applicant, I am free from the use of illegal drugs (controlled substances).Whether, as an employee, I have violated Company policies regarding my having illegal drugs and alcohol in my system while on duty. Whether I am able to perform the essential functions of the job, with or without a reasonable accommodation. Whether I qualify (or continue to qualify) for a leave of absence or other employee benefit. Other (explain): __________________________________________________________I also authorize the Company to use my protected health information in defending against all claims arising out of any action that it may take in response to the results of the above-described test(s). Except as authorized above, the Company may not use or disclose my protected health information unless I provide another authorization, or unless such use or disclosure is specifically required or permitted by law.I understand that the Company will keep all protected health information confidential and in a file that is separate from my personnel file, with limited access to only those who need to know. Hence, I understand that re-disclosure of the protected health information by the Company to those who need to know is possible.This authorization shall become effective immediately and shall remain in effect for six (6) months from the date written below, after which time I must execute a new authorization before any medical information may be disclosed to or used by the Company. I understand that I may revoke this authorization at any time if I send a written notice revoking this authorization to the Company. However, this authorization cannot be revoked to the extent that the Company has taken action in reliance on the authorization prior to receiving the notice of revocation.I understand that treatment, payment, or enrollment in a health plan will not be affected if I refuse to sign this authorization. However, for an applicant seeking employment, failure to sign this authorization will result in the job offer being revoked. For a current employee being tested for illegal drug or alcohol use, failure to sign this authorization will result in the Company making a determination of whether a Company policy has been breached based on the information the Company has in the absence of a test result. For a current employee seeking a leave of absence or reasonable accommodation, failure to sign this authorization may result in the leave or accommodation being denied.I understand that I have the right to receive a copy of this authorization, at any time, upon my request.__________________________________ __________________________Employee / Applicant Signature Date