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UNIVERSITY OF WASHINGTON | Human Resources | Disability Services OfficeHEALTH CARE PROVIDER STATEMENT
Disability AccommodationEMPLOYEE COMPLETES THIS SECTION
Name (Last)(First)Employee\'s Job Title’M.
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How to fill out health care provider statement
How to fill out health care provider statement
01
Obtain the health care provider statement form from the appropriate organization or agency.
02
Fill out the patient's personal information such as name, date of birth, and address.
03
Include details about the patient's medical condition, diagnosis, and treatment plan.
04
Provide any relevant medical history or test results that support the need for the statement.
05
Sign and date the form, ensuring it is completed accurately and legibly.
Who needs health care provider statement?
01
Individuals who are seeking accommodation for a medical condition in school, workplace, or for insurance purposes may need a health care provider statement.
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What is health care provider statement?
Health care provider statement is a document provided by a healthcare provider that outlines the individual's medical condition and related information.
Who is required to file health care provider statement?
Health care providers are required to file the health care provider statement for their patients.
How to fill out health care provider statement?
Health care providers fill out the health care provider statement by documenting the patient's medical condition, treatment plan, and any relevant information.
What is the purpose of health care provider statement?
The purpose of the health care provider statement is to provide accurate information about the individual's medical condition to support claims or requests for healthcare services.
What information must be reported on health care provider statement?
The health care provider statement must include details about the patient's diagnosis, treatment plan, prognosis, and any other relevant medical information.
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