Form 203m - Medical Statement Of Ability To Work
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HELP
SD EForm -
0783
V3
SD DEPARTMENT OF LABOR AND REGULATION
DLR-203-M Rev. 09/12
UNEMPLOYMENT INSURANCE DIVISION
PO BOX 4730
ABERDEEN, SD 57402-4730
FAX: 605.626.3172
MEDICAL STATEMENT OF ABILITY TO WORK
XNAME:
DOB:
Last 4 digits of SSN:
XI most recently worked for
Xas a
XI have recently been under doctor’s care for:
.
XMy physician is:
I
am
am not able to work at this time.
I feel I am physically able to work and will be seeking
work in the following occupation(s):
RELEASE OF INFORMATION: I hereby consent with my signature below to the release of information from
my doctor or medical provider to the Unemployment Insurance Division for the confidential use of that agency
in determining my eligibility for Unemployment Insurance benefits.
X__________________________
X_______________
(Claimant’s Signature)
(Date)
CLAIMANT: Give this form to your physician to complete. Any alterations or changes to the
information below must be initialed by your physician or may void this document.
PHYSICIAN: PLEASE COMPLETE THIS SECTION
The individual named above has applied for Unemployment Insurance benefits. The information requested
below will enable the Unemployment Insurance Division to make a determination of the claimant’s eligibility for
benefits. Your cooperation in providing this information will be appreciated. This information may be provided
to the patient/claimant. (Please note: our office is not responsible for any fees or charges for completing this
document.)
.
.
Nature of CONDITION, ILLNESS OR INJURY:______________________ date began:______________
1.
.
2.
On what date did you first examine this individual for this condition/illness/injury?____________________
3.
Date of most recent examination for this condition/illness/injury:_________________________________
4.
Would continued employment in the most recent employment listed above have been a hazard to this
individual’s health?
Yes
No
5.
Did you advise this individual that this employment was a health hazard, or that he/she should leave this
employment?
Yes
No If yes, when did you advise this individual that the employment was a health
hazard?____________________________.
6.
At the present time is this individual physically able to work in the occupation(s) listed above?
Yes
No
7.
Date was or will be physically able to do this work:__________________________________.
8.
Please describe restrictions/limitations to claimant’s present ability to work: _______________________
__________________________________________________________________________________.
9.
Comments:_________________________________________________________________________.
_____________________________________ ________________________ ____________________
Physician’s Signature
Degree/Title
Today’s Date
Physician’s Name ____________________________________
Clinic Name ____________________________________
Address ____________________________________
Telephone ________________ FAX # ______________
If clarification is needed regarding your responses on this form, who should we contact in your
office?______________.
Please FAX or MAIL this completed form within the next five (5) days to the address at the top of the
form. Thank you for your assistance.
PRINT FOR MAILING
CLEAR FORM
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