IN THE COURT OF COMMON PLEAS
OF
____________
COUNTY
Member Name:
Docket Number:
PACSES Case Number:
Other State ID Number:
PHYSICIAN VERIFICATION FORM
TO BE COMPLETED BY THE TREATING PHYSICIAN
Physician's name: ______________________________________
Physician's license number: ______________________________________
Nature of patient's sickness or injury:
______________________________________
______________________________________
______________________________________
Date of first treatment: ______________________________________
Date of most recent treatment: ______________________________________
Frequency of treatments: ______________________________________
Medication: ______________________________________
The patient has had a medical condition that affects his or her ability to earn income from:
____________
through
____________
If the patient is unable to work, when should the patient be able to return to work? Will there be limitations?
______________________________________
______________________________________
Remarks:
______________________________________
______________________________________
Date:
____________
Signature of Treating Physician: ______________________________________
Physician's address:
______________________________________
______________________________________
______________________________________
Physician's telephone number: ______________________________________
I authorize my physician to release the above information to the
____________
County Domestic Relations Section.
Patient's signature:
____________
Date:
____________
231 Pa. Code r. 1910.29