Forms
How do I complete a Medical Disability Statement, work/school excuse, or referral notice?
Organization ApprovedSource Verified
Summary
Only the doctor places a patient on disability. The Excuse from Work/School covers an appointment already attended, and the Patient Referral Notice is used whenever the doctor refers a patient to an outside facility.
- 1Only the clinic Doctor places a patient on disability; the Medical Disability Statement notifies the employer/school and creates a permanent record.
- 2The Doctor completes the statement and documents the disability on Travel Card Exam Page 1 under Disability TTD/Mod Duty, then places it in the Travel Card and delivers it with the patient to the front desk for rescheduling.
- 3Make a copy for the chart as a permanent record; the patient receives the original. You may fax it for the patient — if faxed, print the fax confirmation and staple it to the clinic copy.
- 4A Medical Disability Statement cannot precede the patient's 1st treatment date at our office, and it is included in any Final Packet or medical records sent.
- 5Excuse from Work/School: used only for an appointment the patient has already attended, never to notify an employer/school of a future appointment.
- 6The form is printed on clinic letterhead, signed by the Doctor, and kept at the front desk; the CA completes it and initials at the bottom, copies it for the chart, and gives the patient the original.
- 7For future appointments, give the patient the clinic business card with appointment notes on the back instead. This document is not part of any Final Packet or records request.
- 8Patient Referral Notice: used whenever the Doctor refers a patient to an outside facility (MRI, pain management, etc.) so the clinic retains control of care as the treating facility.
- 9Ask the patient for available dates/times (the clinic does not provide transportation), call the outside office to schedule with the patient's information ready, then give the patient the provider name and directions.
- 10Note the provider and appointment date/time on Travel Card Exam Page 1 under REFERRALS.
- 11Put a copy of the Patient Referral Notice in the Fax File for 2 days after the appointment to follow up on the outcome and confirm receipt of a report; set a recall for 2 days after the appointment to bring the patient back if treatment was suspended.
- 12If the report is not received by the follow-up date, contact the provider; if the Final Packet was already sent, forward the carrier or attorney a copy of the report on receipt.
Citation
CA Manual, Medical Disability Statement; Excuse from Work/School; Patient Referral Notice, p. Patient Maintenance · Revised 2/9/26Answers source the CA Manual first; the Medisoft guide is used only where the CA Manual does not cover the task.