Get Il Cms-95 2000-2025

The IL CMS-95 form is essential for individuals seeking authorization for disability leave and return to work. This guide provides clear, step-by-step instructions to assist users in completing the form online, ensuring all necessary information is accurately provided.

Follow the steps to complete the IL CMS-95 online form successfully.

1. Click ‘Get Form’ button to access the IL CMS-95 online form and open it in your chosen editor.
2. Enter the patient's full name in the designated field for 'Name of Patient.'
3. Provide the date of birth of the patient in the 'Date of Birth' field.
4. Fill in the social security number in the 'Soc. Sec. Number' field.
5. Complete the present address section by entering the street address, city, state, and zip code.
6. Indicate the employing agency, board, commission, department in the 'Employed by State of Illinois' section.
7. Provide information about the facility where the patient is employed, including the facility's address.
8. In the 'Comprehensive Medical Information' section, detail the diagnosis, subjective symptoms, objective findings, and date of last examination.
9. List the dates of treatment by entering the date of the first visit, last visit, and frequency of visits.
10. Describe any surgeries and medications prescribed in the treatment section.
11. Indicate whether the treatment will substantially improve function and employability by answering yes or no and specifying if applicable.
12. Check the box that reflects the patient's progress and their current physical status.
13. State if the patient has been hospital confined by answering yes or no and providing hospital details if applicable.
14. In the limitations section, check the appropriate boxes and describe any limitations faced by the patient.
15. Complete the physical impairment section by selecting the class that best describes the patient's functional capacity.
16. Assess the extent of disability, answering questions regarding temporary total disability and the anticipated return to work date.
17. Provide any additional remarks in the specified section.
18. The attending physician must sign the form, including their degree, name, office address, city, state, zip code, and phone number.
19. Once all fields are completed, save the changes, download, print, or share the form as needed.

Complete and submit your IL CMS-95 online today to ensure timely processing of your disability leave request.