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How do I fill this out?
To fill out the form, first download it and print it. Next, read the instructions carefully to understand what information is required from you and your physician. Finally, ensure that both sections are completed accurately before submitting to the Health Services Division.
How to fill out the Treating Physician's Clearance to Return to Work?
1
Download and print the form.
2
Read the instructions thoroughly.
3
Complete the employee section.
4
Have your treating physician fill out their section.
5
Submit the completed form to the Health Services Division.
Who needs the Treating Physician's Clearance to Return to Work?
1
Employees returning from medical leave need this form for clearance.
2
Employers require this form to ensure employees are fit to work.
3
Human Resources departments need it for record-keeping.
4
Health Services Division uses it to evaluate employee readiness.
5
Treating physicians need to document patient status for compliance.
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Click on the text areas to edit or fill in your information.
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Download the final version for submission.
What are the instructions for submitting this form?
To submit this form, send it to the Health Services Division at 840 Iwilei Road, Honolulu, Hawaii 96817. You may also fax it to (808) 522-7057. Make sure to send a complete and signed copy to ensure prompt processing and clearance.
What are the important dates for this form in 2024 and 2025?
Check with your HR department for specific important dates related to your clearance process. Generally, forms should be submitted prior to your planned return date. Ensure that both the employee and physician sections are completed timely.
What is the purpose of this form?
The purpose of this form is to ensure that employees returning to the workplace after a medical issue are fit to resume their duties. It provides a formal mechanism for healthcare providers to communicate the employee's condition and restrictions if any. This ensures compliance with workplace safety regulations and protects both the employee and employer.
Tell me about this form and its components and fields line-by-line.
- 1. Employee's Signature: The signature of the employee authorizing the submission.
- 2. Date: The date the form is filled out.
- 3. Physician's Name: The name of the treating physician.
- 4. Physician's Address: Address of the treating physician's practice.
- 5. Phone: Contact number for the treating physician.
What happens if I fail to submit this form?
If the form is not submitted, the employee may face delays in their return to work. Compliance with health regulations could also be at risk, leading to potential issues with employment status.
- Delays in Return to Work: Not submitting the form may postpone the employee's ability to return to their role.
- Risk of Non-Compliance: Failure to complete required health assessments may violate company policy.
- Impact on Salary: Extended absences without clearance may affect payroll and benefits.
How do I know when to use this form?
- 1. After a Medical Leave: To formalize your return when recovering from an injury or illness.
- 2. Before Job Duties Resumption: To ensure compliance with workplace safety protocols.
- 3. For Record-Keeping: To provide necessary documentation for HR and employee records.
Frequently Asked Questions
What is the purpose of this form?
The form is used to obtain medical clearance for employees returning to work.
Who should fill out this form?
Both the employee and their treating physician need to complete the form.
How do I submit the completed form?
Submit the signed form to the Health Services Division either by mail or fax.
Can I edit this form digitally?
Yes, you can edit the PDF using our online editor on PrintFriendly.
What happens if I don’t submit this form?
Failure to submit may result in delays in your return to work.
Is there a deadline for submitting this form?
It's best to submit the form as soon as your physician completes it.
Can I share this form with my HR department?
Yes, you can easily share the form after editing.
How do I sign the document?
You can create an electronic signature and place it on the PDF.
Where do I find this form?
This form is available for download on our website.
Are there any fees associated with using this service?
No, using PrintFriendly to edit and download PDFs is free.
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