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Maritime health declaration fo... MARITIME DECLARATION OF HEALTH Submitted for Port of Gibraltar IMO No ETA No of passengers Next Port Last Port (after Gibraltar) Valid Sanitation Control Exemption/Control Certificate carried on board?

Mpc 400 medical certificate fi... MEDICAL CERTIFICATE GUARDIANSHIP OR CONSERVATORSHIP INSTRUCTIONS FOR COMPLETION Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division This document will be used

Marathon medical certificate f... Race name: Race number: MEDICAL CERTIFICATE I, the undersigned Dr , Doctor of Medicine, Certify that the examination of Mr/Ms Date of birth: Age: reveals no contraindications for participating in

Emergency certificate format LDSS-3955 Page 1 of 2 Rev. 02/07 PATIENT'S NAME (Last) ADDRESS: (Street) CERTIFICATION OF TREATMENT OF EMERGENCY MEDICAL CONDITION (First) (MI) NYS Department of Health Medical Assistance Program

Cg 1280 renewal of certificate... DEPARTMENT OF HOMELAND SECURITY U.S. Coast Guard VESSEL RENEWAL NOTIFICATION APPLICATION FOR RENEWAL RETURN TO: OMB No: 1625-0027 Expires: 06/30/2016 NATIONAL VESSEL DOCUMENTATION CENTER PO BOX 1119

Medical claim form memorial he... Mail Completed Form and Itemized Bill s To Memorial Hermann Health Insurance Company 7737 Southwest Freeway C-97 Attn Medical Claims Houston Texas 77074-1807 MEDICAL CLAIM FORM Group No. Employee s Name EMPLOYEE INFORMATION Social Security No. Date of Birth Sex Male Female Marital Status Single Married Widowed Divorced Current Mailing Address City State Zip Telephone Spouse s Name DOB SS Name of Employer Telephone Employer s Address City State Zi...

Medical certificate of death f... Ministry of Consumer and Business Services Office of the Registrar General Medical Certificate of Death - Form 16 Hospital code number You must use the Stillbirth Registration Form 8 when registering

Centrelink medical certificate... Print Instructions Clear Medical Report for Assessor Customer s details Full name Address Postcode Date of birth / Home phone number ( / Centrelink Reference Number (CRN) Mobile phone number ) Email

Form i medical certificate for... FORM I Medical Certificate for Blind Candidate Certified that, I, Dr. Registration No. have this day of 19 , examined the candidate whose particulars are given below : 1. Name of Candidate : 2. Father

Return work medical certificat... Return to Work Medical Certification FMLA Leave PART 1 TO BE COMPLETED BY EMPLOYEE please print or type Employee Name Date Leave Began First Name Middle Initial Last Name Employee Position Employee Signature Date I certify that on is able to resume Date Name of Employee performing the functions of his/her position with or without reasonable accommodation. Healthcare Provider Signature Date 2008 ADP Resource A5-121-0408.

Workcover medical certificate... Office of Industrial Relations Workers Compensation Regulator Form 86. R Version 5 Queensland workers compensation medical certificate Parts A and E of this medical certificate comprise an approved form under the INSTRUCTIONS Tick if applicable and fill in the information as requested. New claim Claim number Part A - Worker s details I certify that on DD / MM / Y Y Y Y I attended to given names surname Date of birth DD / MM / Y Y Y Y Worker s daytime contact phone number Worker s employer name The worker is/was suffering from list all medical diagnoses relevant to the claim Diagnosis This is a provisional diagnosis if provisional complete Part B Worker was first seen at this practice/hospital for this injury/disease on DD / MM / Y Y Y Y Worker stated date of injury DD / MM / Y Y Y Y Injury/disease is consistent with worker s description of cause Yes Uncertain Detail any pre-existing factors or condition aggravated by the event if not previously supplied Worker s capacity for work not only pre-injury duties Please consider the health benefits of work when certifying the worker s capacity. To return to normal duties from DD / MM / Y Y Y Y For suitable duties from DD / MM / Y Y Y Y to DD / MM / Y Y Y Y complete Part D No capability for any type of work DD / MM / Y Y Y Y to DD / MM / Y Y Y Y complete Part C Days Weeks Unsure Estimated time to return to some form of work duties Medical management Worker will require treatment from DD / MM / Y Y Y Y to DD / MM / Y Y Y Y complete Part C Worker will be reviewed again on DD / MM / Y Y Y Y No further review Diagnostic imaging I have ordered Details Pathology Other investigations Part C - Medical management plan Treatment Medication prescribed Referred to specialist speciality/name Referred to allied health professional discipline/name Detail specify I would like the insurer to arrange a case conference with tick more than one if appropriate Treating practitioner Treating Specialist Treating Allied Health Employer Employer has been contacted Further information Part D - Rehabilitation and return to work plan Approval is given for a suitable duties program with the following guidelines No Occasional Frequent Comments Lifting weight limit kg Bending/twisting/squatting Standing/sitting Use of injured hand/arm Pushing/pulling Operating machinery/heavy vehicle Driving a car Keep wound clean and dry Other considerations specify Restricted hours/days specify I require a suitable duties program to be provided to me for approval Part E - edical/Dental practitioner details please print clearly or use practice or hospital stamp M Practice/hospital name Doctor s name Postal address Preferred method of contact Phone day s /time s Fax Email Signature Date DD / MM / Y Y Y Y www. worksafe. qld. gov.au Claim enquiries WorkCover Queensland 1300 362 128 Self Insurance or other enquiries 1300 362 128 Under the Workers Compensation and Rehabilitation Act 2003 and earlier Queensland workers compensation legislation the workers compensation insurer is authorised to collect the information on this form to process the claimant s application for compensation. Some or all of the information contained in this form may be disclosed to the claimant s employer another insurer medical or allied health providers or any other workers compensation authority in any jurisdiction. This form was approved by the Workers Compensation Regulator on 11 April 2014 pursuant to section 586 of the Workers Compensation and Rehabilitation Act 2003.

Avianca medical certificate fo... Other Medical Condition3 Which 1. To follow up on this requirement it is necessary for the treating physician to fill out this form or send a medical certificate with the information required herein. This document must be sent to the email serviciosespeciales centrosolucionavianca.com at least 24 hours before the scheduled flight departure for routes in Colombia and 48 hours for international routes. This email is required to continue processing the application for the special service. 2. See the list of equipment approved by the FAA Oxygen link http //www. avianca.com/Inicio/Navegacion/ViajaConNosotros/Preparando el Viaje/es/Servicios Especiales. htm 3. See the Medical Guide for authorization for the transport of passengers issued by the Civil Aviation Administration on 23 July 2008. MEDICAL CERTIFICATE Dear Attending Physician Please mark an X in the medical case that the traveler presents Need for supplemental oxygen on board Oxygen Concentrator POC. The Federal Aviation Administration FAA prohibits the use of personal oxygen units during flight because they contain compressed gas or liquid oxygen and are considered hazardous materials. However the FAA recently issued guidelines permitting the onboard use of certain portable oxygen concentrators. Personal oxygen concentrator Transport Concentrator2 Brand Confirmation of Pregnant Traveler over 30 weeks for international and domestic flights. Other Medical Condition3 Which 1. To follow up on this requirement it is necessary for the treating physician to fill out this form or send a medical certificate with the information required herein* This document must be sent to the email serviciosespeciales centrosolucionavianca*com at least 24 hours before the scheduled flight departure for routes in Colombia and 48 hours for international routes. This email is required to continue processing the application for the special service. 2. See the list of equipment approved by the FAA Oxygen link http //www. avianca*com/Inicio/Navegacion/ViajaConNosotros/Preparando el Viaje/es/Servicios Especiales. htm 3. See the Medical Guide for authorization for the transport of passengers issued by the Civil Aviation Administration on 23 July 2008. Special medical conditions link or directly from the page of the FAA https //www. faa*gov/about/initiatives/cabinsafety/portableoxygen/ GENERAL INFORMATION Traveler s full name Identity document number Type of document Confirmation/reservation number Flight number / date Traveler s phone numbers including area or country code Phone numbers of a relative at the place of origin including the country or area code MEDICAL INFORMATION This information must be filled out only by the attending physician of the Traveler in the fields that apply. Age of the Traveler Start date of the medical condition in question day / month / year Diagnosis Medical treatments Surgery ies and their date s Current condition of the patient their state of consciousness ability to walk unaided etc* Do they require any medication Which If the event supplemental oxygen in flight is required For the use of an oxygen concentrator POC LPM and brand of the equipment I Dr.

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