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Reinstatement Form Unit 1


Medical Documentation Criteria Changes

Effective August 30, 2016 there are changes to the Medical Documentation Criteria required for reinstatement from a medical leave for all hourly personnel.

When reinstating from a medical leave, the medical documentation must include ALL SEVEN (7) of the following criteria:

  1. The reinstatement form must include the physician's name and phone number.
  2. Date statement was written - must be seen/treated no later than Day 2 of medical absence.
  3. Diagnosis or diagnostic code.
  4. Dates of total disability must include start date and end date.
  5. Dates of treatment must include start and end dates of medical coverage.
  6. Return to work date, must include the return to work status as with or withhout restrictions.
  7. Physician's signature (NOTE: medical documentation must be signed by treating physician MD or DO. All other notes signed by other medical professionals will not be accepted; list includes but is not limited to PA, RN, RNP, MA, LLP, LMSW, and ACSW. Rubber stamps, electronic signatures, copies/faxes are not permitted.)

Employees returning from a medical leave of absence are required to report to the Plant Employment Office for reinstatement processing in advance

of returning to work to ensure they are available at the start of their respective shift. The employee will be considered to be "at work" for the purpose of attendance and paid time will commence upon reporting to their workstation.

Please refer to the above attached reinstatement form for Employment Office reinstatement hours.

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