The 90 California forms that ask for a clinician's input, from SDI and workers' comp reports to DMV placards, IHSS certifications, POLST and Medical Baseline.
This page lists the 90 California forms that ask for a clinician's input, grouped by program. Workers' comp claims start with the Doctor's First Report, Form 5021, and continue with PR-2 progress reports and the DWC RFA. EDD's DE 2501 Part B certifies State Disability Insurance claims. DMV's REG 195 covers disabled person placards and plates, and the uniform 61-211 handles drug prior authorization and step-therapy exceptions with health plans. PG&E, SDG&E and SCE each have a Medical Baseline application.
Send two copies of the 5021 to the insurer within 5 days of the first exam, and file a PR-2 at least every 45 days. Most DE 2501 certifications go through SDI Online, and EDD doesn't accept rubber-stamped signatures. New school immunization medical exemptions are issued only in CAIR-ME. The POLST must be completed in English, though translations exist for reference. 21 forms here have a Spanish version, including the DE 2501, the CW 61 and the SOC 873.
Initial physician report of every occupational injury or illness: history, findings, ICD-10 diagnoses, treatment and work status.
DWC Form PR-2Periodic or event-driven progress report from the primary treating physician on findings, diagnoses, treatment plan and work status.
DWC Form RFAPhysician's request to the claims administrator to authorize specific medical treatment, goods or services, triggering utilization review.
Treating physician's initial evaluation of permanent disability (whole person impairment, apportionment, work restrictions, future medical care) once the patient is permanent and stationary.
DWC-AD 10133.36Tells the employer the permanent work capacities and activity restrictions so it can offer regular, modified or alternative work or issue the Supplemental Job Displacement voucher.
QME Form 110Panel QME's notice to the parties of the scheduled comprehensive medical-legal evaluation.
Proof of service of a comprehensive medical-legal report on each party (Labor Code 4062.3(i)).
DWC Form 9783Aviso de Designación Previa de Médico Personal
Employee's advance designation of a personal physician or medical group to treat a future work injury, with the physician's agreement.
Treating physician's permanent and stationary report for disability ratings under the older 1997 Permanent Disability Rating Schedule.
Asks the Disability Evaluation Unit to rate a panel QME's report in an unrepresented case.
Summary of the panel QME's conclusions on disputed medical issues (P&S status, impairment, causation, apportionment, future care, return to work) in unrepresented cases.
QME Form 112Evaluator's request for a 30-day extension to serve a medical-legal report (e.g. lab or test results not received).
Licensed provider's declaration that an attached mental health record must not be seen or copied by the injured employee because of substantial risk of harm (Health & Safety Code 123115(b)).
QME Form 123Evaluator's disclosure of a disqualifying conflict of interest (or statement that none exists) in a specific case, with the parties' objection or waiver.
Solicitud de beneficios del Seguro por Incapacidad (DI)
Certifies that the claimant is unable to do regular or customary work because of illness, injury, pregnancy or surgery, with diagnosis, ICD codes and expected return-to-work date, to establish a California State Disability Insurance (DI) claim.
DE 2501FCertifies that the care recipient has a serious health condition and requires care by the claimant (with diagnosis, ICD codes, estimated duration and hours per day of care) for a California Paid Family Leave care claim.
Extends an existing California DI claim by updating treatment status, diagnosis/ICD codes, next appointment and the new estimated return-to-work date.
Certifies that the care recipient still needs care so a California Paid Family Leave care claim can continue beyond the originally certified period.
Certifies the non-work-related disability of a California state employee covered by Nonindustrial Disability Insurance (NDI) instead of SDI.
Certifies the care recipient's serious health condition and need for care for a California state employee's NDI Family Care Leave claim.
CalPERS-1204Medical specialist's opinion on whether a CalPERS member is substantially incapacitated from the usual duties of their position, permanently or for at least 12 months, for disability or industrial disability retirement.
Treating physician's statement supporting a LACERA member's application for service-connected or nonservice-connected disability retirement, assessed against the County class specification.
Treating physician or therapist certifies whether a Cash Balance Benefit Program participant's impairment is total and permanent (expected to prevent creditable service for at least one year), its etiology and duration.
Reports an eye examination (refraction, visual acuity, fields, conditions) for an applicant who did not meet DMV's visual acuity screening standard.
Gives DMV Driver Safety a medical professional's evaluation of a condition that may affect the patient's ability to drive safely, for a licensing decision or medical reexamination.
Mandatory physician report (H&S Code 103900) of a patient aged 14+ diagnosed with a disorder characterized by lapses of consciousness, Alzheimer's/related disorders or similar conditions; the local health officer forwards it to DMV for licensing action.
Solicitud Para Reexaminación de Conductor
Asks DMV to reevaluate a driver's ability to drive safely because of a physical, mental or vision condition or observed unsafe driving.
DL 546AReporte Médico Sobre La Salud
Physician's certification that the applicant has no impairment precluding driving a house car over 40 feet or being a driving school instructor (non-commercial health requirement).
Medical provider certifies that the driver has a medical condition preventing them from providing a deep-lung breath sample, to exempt them from an ignition interlock requirement.
Applies for a permanent, temporary or travel disabled person (DP) parking placard or DP license plates, with the medical provider's certification of the qualifying disability.
Clarifying information from the applicant's treating professional that the Access evaluator may request to decide ADA paratransit eligibility after the in-person evaluation.
Certifies a disability category (1-19) that limits use of fixed-route transit so the applicant gets the Clipper Access discount card for Bay Area transit.
Professional's list of diagnoses and explanation of why the applicant cannot independently use SacRT bus or light rail, required for SacRT GO ADA paratransit eligibility.
Licensed provider's description of the applicant's functional abilities and limits on MTS bus and trolley, used with the in-person assessment to decide MTS Access ADA paratransit eligibility.
Physician statement of a qualifying medical disability so an applicant without Medicare/SSI/DMV placard/VA documentation can get a disabled reduced-fare PRONTO photo ID.
Prior authorization request for outpatient drugs under the Medi-Cal Rx pharmacy benefit (all Medi-Cal members, FFS and managed care).
Prior authorization request for enteral nutrition products under Medi-Cal Rx.
Proof of the oral health assessment required by May 31 for children in kindergarten or first grade if not previously enrolled (Education Code 49452.8).
Pre-admission medical assessment and immunization record required for a child entering a licensed child care center (22 CCR 101220).
Health screening (general health, TB) showing a licensee, employee or volunteer can perform their duties in a licensed community care or child care facility.
Physician's evaluation and written instructions allowing child care staff to provide G-tube feeding, hydration or liquid medication.
Issues a standardized temporary or permanent medical exemption from required school and child care immunizations, reviewable by CDPH.
Standard adult TB risk assessment that clinicians use to decide on TB testing, commonly accepted for employment, health care worker, college and other TB clearance requirements.
Standard pediatric TB risk assessment used to decide on TB testing, accepted by schools and child care programs that require TB screening at entry.
Documents TB risk assessment (and testing if indicated) required for K-12 school employees, contractors and volunteers, ending in a Certificate of Completion for the employer.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable medical order for CPR, medical interventions and artificially administered nutrition for seriously ill or frail Californians (Probate Code 4780 et seq.).
Documents the attending physician's eligibility determinations, required counseling and request dates under California's End of Life Option Act when an aid-in-dying drug is prescribed.
Reports whether the patient ingested the aid-in-dying drug and the circumstances of death.
Consulting physician confirms terminal diagnosis, prognosis, capacity and voluntariness of a patient requesting an aid-in-dying drug.
The '5150' application: documents probable cause that a person is a danger to self, danger to others or gravely disabled due to a mental health or severe substance use disorder, starting an involuntary hold of up to 72 hours.
Certifies a person for 14 days of intensive treatment (or an additional 30 days for grave disability) after a 72-hour hold, triggering a certification review hearing.
Records a clinician's sworn capacity assessment of a proposed conservatee (mental functioning deficits and capacity to consent to medical treatment, placement, dementia medications, etc.) for a probate conservatorship hearing.
JV-220(A)Prescribing physician's statement supporting an application for a juvenile court order to administer psychotropic medication to a dependent or ward in foster care (diagnoses, medications, doses, side effects, alternatives tried).
Short renewal version of JV-220(A) asking the juvenile court to continue the same psychotropic medication at the same maximum dose for a child in foster care.
A licensed behavioral health professional's sworn statement that they examined (or tried to examine) the respondent within 60 days and that the respondent meets, or likely meets, the diagnostic criteria for CARE Act proceedings.
Certifies an additional 14 days of intensive treatment for a person who presents an imminent threat of suicide, supported by affidavits.
Attachment to GC-335 documenting the proposed conservatee's ability to perform everyday activities, used where major neurocognitive disorder (dementia) powers are sought.
Documentación escrita de los expedientes médicos del/de la paciente
Optional attending-physician statement that the patient has a serious medical condition (H&S Code 11362.7) and that medical marijuana use is appropriate, supporting a county-issued Medical Marijuana Identification Card.
CDPH 110aReports a case or suspected case of a reportable communicable disease or condition (Title 17 CCR section 2500), except HIV/AIDS, tuberculosis and DMV-reportable conditions, to the local health department.
BCIA 8572Written mandated report of known or suspected child abuse or neglect under the Child Abuse and Neglect Reporting Act (Penal Code section 11166).
Written mandated report of suspected abuse, neglect or financial abuse of an elder (60+) or dependent adult (WIC 15630).
Cal OES 2-920Written report by a health practitioner who treats a wound or injury caused by assaultive or abusive conduct or a firearm (Penal Code section 11160).
Provider report of active, suspected or confirmed tuberculosis (and TB infection where reportable) to the local health department.
62-3481-BCertifies that a full-time resident uses a life-support device or needs extra heating/cooling for a qualifying condition so the account gets the Medical Baseline allowance and outage notifications.
Licensed practitioner certifies life-support devices, heating/cooling needs and duration so the household receives the CPUC Medical Baseline allowance (16.5 kWh/day or 0.822 therms/day) and outage notifications.
SCE 14-746Certifies that a resident needs electrically operated life-support/medical devices or extra heating/cooling so the household receives the CPUC Medical Baseline allowance (extra baseline energy, outage notifications).
Certifying professional confirms the applicant's hearing, vision, speech, mobility or cognitive disability so the state program provides free specialized telephones and communication equipment.
S 504-02Tenant/applicant requests a disability accommodation (unit modification, extra bedroom, live-in aide, policy exception) and names a professional whom HACLA contacts to verify the disability-related need.
Qualified health professional certifies use of qualifying devices (electric wheelchair, home dialysis cycler, oxygen concentrator, ventilator) or extraordinary heating/cooling needs for a $15/month MED rate discount.
BOE-19-DCPhysician or surgeon certifies that a homeowner is severely and permanently disabled and states the disability-related requirements of a replacement home, so the Proposition 19 base-year value transfer (BOE-19-D) can be granted.
BOE-62-APhysician certifies that a claimant or spouse is severely and permanently disabled for the one-time base-year value transfer under Revenue and Taxation Code section 69.5 (Proposition 110 rules for earlier transfers).
Physician certification of a disability that prevents drawing and holding a bow, so the hunter may use a crossbow or bow-locking device during archery seasons.
Physician certification of a visual disability so the hunter may use a telescopic sight on a muzzleloader during muzzleloader-only seasons.
Physician certification of a mobility impairment so the hunter can get the Mobility Impaired Disabled Persons Motor Vehicle Hunting License to shoot from a stationary vehicle.
Eye doctor certification of legal blindness (acuity 20/200 or field 20 degrees or less, Fish & Game Code §7151(a)(1)) for a free sport fishing license.
Physician certification that a California resident is permanently unable to move without an assistive mobility device (Fish & Game Code §7151(a)(4)) for a free fishing license.
Certification that the applicant is developmentally disabled (Fish & Game Code §7151(a)(3)) for a free sport fishing license.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Within 5 days of the initial exam. The treating physician sends two copies to the employer's workers' compensation insurer or the insured employer. Pesticide cases are also reported by phone to DIR and the local health officer within 24 hours. The physician signs with an original signature, not a stamp, under penalty of perjury. Under 8 CCR 9789.14 the report is not paid separately; it is included in the E/M visit.
Most certifications go through SDI Online, which needs a California DCA license and a myEDD account with ID.me. On paper, Part B of the DE 2501 is mailed to EDD with the claimant's Part A within 49 days of the disability start. EDD's posted PDF is a sample only, because paper claim forms are barcoded and ordered from EDD. Rubber-stamped signatures are not accepted. To extend a claim, complete the DE 2525XX within 20 days.
A licensed physician, surgeon, PA, NP or certified nurse-midwife can certify items 2 to 8. Chiropractors can certify items 6 to 8, podiatrists foot and ankle conditions, and ophthalmologists or optometrists vision only (item 1). The provider certifies under penalty of perjury, writes a legible diagnosis rather than an ICD code alone, and keeps the substantiating records. One form covers temporary placards of up to 180 days and permanent ones.
Only through CAIR-ME. Since January 1, 2021, every new school or child care medical exemption must be issued on the California Immunization Registry Medical Exemption website, and there is no paper form. The parent applies first and gives you an application number. A California-licensed MD or DO registered in CAIR-ME enters the exemption and prints the standardized form, which the parent gives to the school. CDPH reviews physicians who issue 5 or more a year.