SFDC: 500Kh00000YggUZIAZ E105 vs 10.
18 10122386
Behavioral Health Physician Statement
This form needs to be completed by treating provider or treating provider
office only Fax to 1-855-579-1799 or by email to
[email protected] Patient Name: Kiya Manson Patient Date of Birth: December 24, 1990
Patient Job Title: Hub Associate Case Number: 10122386
Requested Leave Start January 21, 2025 Requested Return to August 20, 2025
Date: Work:
Physical Demand: Regular Full Time
1. Diagnostic Information
Primary Diagnosis: _________________________________________ ICD-10: __________ Date of Onset: ___/___/____
Secondary Diagnosis impacting work: __________________________ ICD-10: __________
Is the patient’s primary condition due to injury or illness arising out of the patient’s employment? [ ] No [ ] Yes
2. Treatment Information
• Office visits: Most recent visit date: ____/____/_____ Next visit: ____/____/_____
• If Hospitalized, Admitted on: _____/_____/_____ Discharged on: _____/_____/_____
• If Patient referred to specialist, Providers Name_______________________ Specialty _________Phone#__________
3. Clinical and Functional Assessment
Do you consider your patient to be totally impaired from working? [ ] No [ ] Yes
If yes, as of what date? ____/____/____, with an actual / expected return to work date of ___/____/____
If yes, as supported by the following rationale based on patients most recent evaluation on ___/____/____ (citing
Mental Status Exam findings, patient’s functional impairments, your assessment).
Within Normal
Date of Evaluation: Limits Impaired As Evidenced By:
A. General/Behavior Observations [] []
B. Language/Thought functioning [] []
C. Emotional functioning (Mood/
Affect)
[] []
D. Cognitive functioning [] []
1. Focus/Attention/Memory [] []
2. Insight/Judgement/ Problem
Solving/Decision making
[] []
3. Multitasking [] []
Please upload your document via the Self-Service Portal, e-mail to [email protected] or fax to 1-855-579-1799
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4. Return to Work Planning
What is the estimated date of the patient’s release to modified duty ___/____/____and to full duty ___/____/____
Are there any temporary work restrictions and/or accommodations which would allow your patient to return to work?
[ ] No [ ] Yes, If Yes please specify by providing objective quantification e.g. work for 6 hr/day for 4 weeks.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Provider’s Name and Credentials (MD, DO, etc.) Specialty Date:
Signature Phone: Fax:
