SICK LEAVE BANK REQUEST FORM (Please Print or Write Legibly) DATE: NAME: ADDRESS: DEPARTMENT: LENGTH OF SERVICE: NATURE OF ILLNESS: PHYSICIANS NAME: PHYSICIANS ADDRESS: SIGNATURE: READ AND SIGN MEDICAL RELEASE FORM BELOW AND SEND YOUR REQUEST TO ANY ONE OF THE COMMITTEE MEMBERS LISTED: Kathleen DiCiaccio – Personnel MaryAlice Lally – Personnel Martha Pantanella - DPW AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS I hereby authorize the appointed Sick Bank Committee of the Somerville Municipal Employees Association to be furnished with any information and facts regarding this injury/illness, including reports and records, results of diagnosis, treatment and prognosis, estimates of disability, and to furnish them copies of such reports. This information is to be used for the purpose of evaluating and handling my request for additional sick time from the S.M.E.A. Unit B Sick Leave Bank and for no other purpose, now or in the future. Signature Date PLEASE SUBMIT ANY AND ALL DOCUMENTATION PERTAINING TO ILLNESS.
Pages to are hidden for
"SICK LEAVE BANK REQUEST FORM - DOC"Please download to view full document