Grand Traverse County, MI · Grand Traverse County
Physician’s Form Regarding Disability
This form lets a client authorize medical information release and asks a treating health care provider to describe a condition that restricts or prevents work.
At a glance
- Issued by
- City of Grand Traverse County · Grand Traverse County, Grand Traverse County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- gtcountymi.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form is for a client who reports a condition that restricts or prevents their ability to work and their treating physician or other health care provider. The client authorizes release of information to the 13th Circuit Court, Family Division and Friend of the Court. The provider supplies diagnosis, treatment and work-capacity details, including restrictions and an anticipated return-to-work date.
Who needs it
A client reporting a condition that restricts or prevents work and their treating physician or other health care provider complete the form.
How to submit it
The form names the Friend of the Court, 13th Circuit and Family Court, at 328 Washington St Ste 200, Traverse City, MI 49684. It also lists a fax number and email address.
About notarization
This form is signed without a notary; the client signs and dates the authorization, and the treating provider signs and dates the medical information section.
How to submit this form
- 1
Download the Form
Download the Physician’s Form Regarding Disability.
- 2
Complete the Authorization
Enter the client name and docket number, then sign and date the authorization to release information.
- 3
Have the Provider Complete It
Ask the treating physician or other health care provider to complete and sign the medical information section.
- 4
Submit the Form
Use the Friend of the Court address listed on the form; its contact details also include a fax number and email address.
Frequently asked questions
- Do I need a notary for the Physician’s Form Regarding Disability?
- No. The form has no notary block; the client signs and dates the authorization, and the treating provider signs and dates the medical information section.
- What information does the physician provide?
- The provider gives the diagnosis, treatment plan, anticipated treatment and recovery details, next appointment date, work capacity, restrictions, and return-to-work estimate.
- How do I submit the Physician’s Form Regarding Disability?
- The form names the Friend of the Court, 13th Circuit and Family Court, at 328 Washington St Ste 200, Traverse City, MI 49684, and lists a fax number and email address.