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STATE EMPLOYEES LEAVE BANK REQUEST MEDICAL CERTIFICATION FORM TO BE COMPLETED BY EMPLOYEES TREATING PHYSICIAN PATIENTS NAME: DIAGNOSIS(ES): ICD CODE(S): SUMMARY OF TREATMENT(S) & PROCEDURE(S): START

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What is leave bank medical certification?

Leave bank medical certification is a form that needs to be filled out by employees who are requesting extended leave from work due to medical reasons.

Who is required to file leave bank medical certification?

Employees who are seeking extended leave from work due to medical reasons are required to file leave bank medical certification.

How to fill out leave bank medical certification?

Leave bank medical certification must be filled out completely with accurate medical information by the employee and their healthcare provider.

What is the purpose of leave bank medical certification?

The purpose of leave bank medical certification is to provide documentation of a medical condition that requires extended leave from work.

What information must be reported on leave bank medical certification?

Leave bank medical certification must include details of the medical condition, expected duration of leave, and healthcare provider's contact information.

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