All 322 federal forms in the library, from the Department of Labor, SSA, VA and TRICARE, DOT, FAA, CMS, OPM, IRS, CDC, FDA and USCIS, grouped by program.
This page lists the 322 federal forms in the library, grouped by program, with each group linking to its program page. The ones clinicians see most are the FMLA certifications WH-380-E and WH-380-F, the SSA medical source statements HA-1151 and HA-1152, VA Form 21-2680 and the Disability Benefits Questionnaires, and the DOT driver physical forms MCSA-5875 and MCSA-5876. The largest groups are VA and TRICARE (96 forms), FAA medical certification (66) and Medicare (34).
Routing differs by agency. FMLA forms go back to the patient for the employer and are never sent to DOL. SSA medical source statements arrive per case from a hearing office or the claimant's representative. DBQs go to the Veteran to submit, and VA does not pay for completing them. DOT physicals need a certified medical examiner on FMCSA's National Registry, and the I-693 immigration exam is only for USCIS-designated civil surgeons. Vero Documents fills PDF forms from the visit note and the chart; the clinician reviews and signs.
CA-17Informe de estado de servicio
Reports an injured federal employee's work restrictions and ability to return to regular or modified duty after an injury.
Informe del médico tratante
Attending physician's report of diagnosis, objective findings, causal relationship to employment, disability periods and work limitations for a federal employee's compensation claim.
Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas
Treating physician's assessment of an injured worker's work capacity and physical restrictions (sitting, lifting, reaching, etc.) for an accepted musculoskeletal condition.
Provider's prior-authorization request for procedures, testing, therapy, DME and other services for FECA, Black Lung and Energy claimants before treatment is rendered.
Employing agency's written authorization (up to 60 days) for a physician or facility to examine and treat a federal employee for a traumatic injury, with the attending physician's initial report on the reverse.
CA-27Prescriber's certification and letter of medical necessity required for OWCP to authorize opioid prescriptions beyond the initial fill limits for a FECA claimant.
Evaluación de la capacidad de trabajo Condiciones psiquiátricas / psicológicas
Treating physician or psychologist's assessment of an injured worker's capacity to work and restrictions for an accepted psychiatric/psychological condition.
Physician's opinion on whether a black lung beneficiary can manage benefit payments in their own interest, used to decide whether to appoint a representative payee.
Treating physician's certification requesting DOL prior approval of durable medical equipment, oxygen and home nursing for a black lung beneficiary (authorization up to one year, renewable).
ILO-based classification of a miner's chest image for pneumoconiosis, used to determine eligibility for black lung benefits.
CM-933bSecond (quality/validation) B-reader rereading of a miner's chest image for black lung claims.
Examining physician's medical and occupational history, physical exam and reasoned opinion on pneumoconiosis, respiratory impairment and causation for a black lung benefits claim.
Reports resting/exercise arterial blood gas results for a black lung claimant under the quality standards of 20 CFR 718.
CM-2907Reports pulmonary function (spirometry) results with tracings for a black lung claimant under 20 CFR 718 Appendix B standards.
Treating physician certifies a face-to-face exam and either requests an in-home assessment or attaches a letter of medical necessity (plan of care) for home health care, nursing home or assisted living for an EEOICPA-covered condition.
Provider's prior-authorization request for medical services (procedures, outpatient services, drugs by HCPCS/CPT/NDC/revenue code) for an EEOICPA claimant's accepted condition.
Prior-authorization request for durable medical equipment for an EEOICPA claimant, supported by the physician's prescription and letter of medical necessity.
Prior-authorization (initial, re-authorization, amendment or correction) of a rehabilitative therapy plan (e.g. PT, OT, speech, chiropractic) for an EEOICPA claimant.
Prior-authorization request for an organ/tissue transplant for an EEOICPA claimant, with the treating physician's letter of medical necessity.
Home health agency's prior-authorization request (initial, re-authorization, amendment) for a home health care service plan for an EEOICPA claimant.
Employer's authorization for a physician of the employee's choice to examine/treat a Longshore Act (or extension) injury, with the physician's initial report of injury and treatment on the reverse.
Attending physician's progress and final (discharge) report on a Longshore Act injury, including disability status and any permanent partial impairment.
Evaluación de la capacidad de trabajo Condiciones cardiovasculares / pulmonares
Treating physician's assessment of work capacity, physical demand limits and functional class for an injured worker with an accepted cardiovascular or pulmonary condition.
Certificado del proveedor de atención médica para la condición de salud grave de un empleado conforme a la Ley de Ausencia Familiar y Médica
Certifies the employee's own serious health condition, its onset, expected duration and the amount of FMLA leave (continuous, reduced schedule or intermittent) the employee needs.
Certificado del proveedor de atención médica para la condición de salud grave de un familiar conforme a la Ley de Ausencia Familiar y Médica
Certifies a family member's serious health condition and the care the employee needs to provide, supporting the employee's FMLA leave to care for that family member.
Certificado de lesión o enfermedad grave de un miembro actual del servicio para la licencia de cuidador militar conforme a la Ley de Ausencia Familiar y Médica
Certifies a current servicemember's serious injury or illness incurred or aggravated in the line of duty and the care needed, supporting up to 26 weeks of FMLA military caregiver leave for a family member.
Certificado para lesión o enfermedad grave de un veterano para la licencia de cuidador de un militar conforme a la Ley de Ausencia Familiar y Médica
Certifies a covered veteran's serious injury or illness (within five years of discharge) and the care needed, supporting FMLA military caregiver leave for a family member.
Records a physical examination showing whether the Veteran, spouse, surviving spouse or parent is housebound or needs the regular aid and attendance of another person, for the A&A/Housebound add-on to compensation or pension.
Documents the Veteran's thoracolumbar spine conditions, including range of motion, radiculopathy and incapacitating episodes so VA can decide service connection and assign a disability rating.
Documents the Veteran's foot conditions including flatfoot (pes planus), plantar fasciitis and other foot injuries so VA can decide service connection and assign a disability rating.
Documents the Veteran's headaches including migraines, frequency of prostrating attacks and work impact so VA can decide service connection and assign a disability rating.
Documents the Veteran's hypertension or isolated systolic hypertension, including blood pressure readings on 3 different days so VA can decide service connection and assign a disability rating.
Documents the Veteran's knee and lower leg conditions, including range of motion, instability and meniscal conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's mental disorders (other than PTSD and eating disorders) under DSM-5, including occupational and social impairment so VA can decide service connection and assign a disability rating.
Documents the Veteran's cervical spine conditions, including range of motion and radiculopathy so VA can decide service connection and assign a disability rating.
Documents the Veteran's peripheral nerve conditions (radiculopathy, neuropathy, nerve injuries) other than diabetic neuropathy so VA can decide service connection and assign a disability rating.
Documents the Veteran's the current severity of already service-connected PTSD (review/increase claims) so VA can decide service connection and assign a disability rating.
Documents the Veteran's scars and disfigurement (size, location, pain, instability) so VA can decide service connection and assign a disability rating.
Documents the Veteran's shoulder and arm conditions, including range of motion so VA can decide service connection and assign a disability rating.
Documents the Veteran's sleep apnea, including sleep study confirmation and CPAP use so VA can decide service connection and assign a disability rating.
Prescriber justifies a formulary drug with prior authorization criteria or a non-formulary drug (medical necessity) so TRICARE covers it at network and home-delivery pharmacies (PA also at military pharmacies).
VA Form 10-10172Community care provider asks VA to authorize services not on the original referral (extra visits, new specialty care, procedures, home/long-term care) or DME, prosthetics, home oxygen and therapeutic footwear.
Documents the Veteran's ankle conditions, including range of motion, flare-ups and repetitive-use testing so VA can decide service connection and assign a disability rating.
Documents the Veteran's arterial and venous conditions, including varicose veins so VA can decide service connection and assign a disability rating.
Prescriber explains the patient's experience with the A-rated generic and clinical justification for dispensing the brand-name drug.
Ordering provider certifies medical necessity, HCPCS codes, quantity and length of need for durable medical equipment (incl. CPAP and capped rentals) for TRICARE East claims.
Diagnosing provider documents that DSM-5 autism spectrum disorder criteria are met (with/without intellectual or language impairment, comorbidities) for the Autism Care Demonstration.
Ordering provider attests diabetes diagnosis, insulin regimen, diabetes education and recent in-person evaluation for initial TRICARE CGM approval or replacement receiver.
Documents the Veteran's diabetes mellitus, treatment (insulin, regulation of activities) and complications so VA can decide service connection and assign a disability rating.
Documents the Veteran's diabetic sensory-motor peripheral neuropathy of the extremities so VA can decide service connection and assign a disability rating.
Documents the Veteran's ear conditions, including vestibular (vertigo/Meniere's) and infectious conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's esophageal conditions including GERD and hiatal hernia so VA can decide service connection and assign a disability rating.
Documents the Veteran's eye conditions, including visual acuity and visual fields so VA can decide service connection and assign a disability rating.
Documents the Veteran's fibromyalgia so VA can decide service connection and assign a disability rating.
Documents the Veteran's hand and finger conditions, including range of motion and ankylosis so VA can decide service connection and assign a disability rating.
Documents the Veteran's heart conditions (ischemic heart disease, arrhythmias, valvular disease, cardiac surgery), including METs/functional capacity so VA can decide service connection and assign a disability rating.
Documents the Veteran's hip and thigh conditions, including range of motion so VA can decide service connection and assign a disability rating.
ABA supervisor submits the initial assessment and treatment plan to obtain TRICARE ACD authorization for ABA services.
Documents the Veteran's intestinal conditions (IBS, IBD, intestinal surgery, infections) so VA can decide service connection and assign a disability rating.
Ordering provider attests that the beneficiary meets TRICARE criteria for a laboratory developed test (incl. genetic tests), with CLIA lab details and codes.
Documents the Veteran's male reproductive organ conditions including erectile dysfunction and prostate cancer so VA can decide service connection and assign a disability rating.
Requests extension of an existing TRICARE behavioral health authorization with updated diagnoses, medications, clinical progress and discharge plan.
Requests initial TRICARE authorization for inpatient, residential (non-RTC), partial hospitalization, intensive outpatient or substance use disorder treatment.
Referring provider documents a definitive autism spectrum disorder diagnosis, severity, comorbidities and validated assessment tool so a child can enter ABA under the TRICARE Comprehensive Autism Care Demonstration (ACD).
Documents the Veteran's respiratory conditions (asthma, COPD, interstitial lung disease, etc.), including PFT results so VA can decide service connection and assign a disability rating.
Documents the Veteran's sinusitis, rhinitis and other conditions of the nose, throat, larynx and pharynx so VA can decide service connection and assign a disability rating.
Documents the Veteran's skin diseases (dermatitis, eczema, psoriasis, etc.), body-area coverage and treatment so VA can decide service connection and assign a disability rating.
Documents the Veteran's wrist conditions, including range of motion so VA can decide service connection and assign a disability rating.
Documents the Veteran's amputations (level, prosthesis use, residual limb) so VA can decide service connection and assign a disability rating.
Documents the Veteran's amyotrophic lateral sclerosis (ALS) so VA can decide service connection and assign a disability rating.
Notifies Humana Military of a behavioral health discharge, with discharge plan and 7-day and 30-day follow-up appointments.
Documents the Veteran's bone and other skeletal conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's breast conditions and disorders, including breast surgery so VA can decide service connection and assign a disability rating.
Documents the Veteran's central nervous system and neuromuscular diseases not covered by a more specific DBQ so VA can decide service connection and assign a disability rating.
Physician order/certificate of medical necessity that must accompany CHAMPVA claims for certain durable medical equipment (e.g., insulin pumps, barrier-free lifts).
Provider obtains CHAMPVA approval before non-emergent inpatient mental health/substance use care, RTC, PHP, IOP, dental care, organ and bone marrow transplants and other services listed in the CHAMPVA Guidebook.
Documents the Veteran's chronic fatigue syndrome so VA can decide service connection and assign a disability rating.
Documents the Veteran's cranial nerve diseases so VA can decide service connection and assign a disability rating.
Documents the Veteran's eating disorders so VA can decide service connection and assign a disability rating.
Documents the Veteran's elbow and forearm conditions, including range of motion so VA can decide service connection and assign a disability rating.
Requests TRICARE authorization (initial or extension) for electroconvulsive therapy with clinical summary and treatment response.
Documents the Veteran's endocrine diseases other than thyroid, parathyroid or diabetes so VA can decide service connection and assign a disability rating.
Documents the Veteran's gallbladder conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's gynecological conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's hematologic and lymphatic conditions, including leukemia and lymphoma so VA can decide service connection and assign a disability rating.
Documents the Veteran's hepatitis, cirrhosis and other liver conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's abdominal, inguinal and femoral hernias so VA can decide service connection and assign a disability rating.
Documents the Veteran's HIV-related illnesses so VA can decide service connection and assign a disability rating.
Documents the Veteran's infectious diseases other than HIV, chronic fatigue syndrome or tuberculosis so VA can decide service connection and assign a disability rating.
Documents the Veteran's kidney conditions (renal dysfunction, dialysis, stones) so VA can decide service connection and assign a disability rating.
Documents the Veteran's loss of the sense of smell and/or taste so VA can decide service connection and assign a disability rating.
Documents the Veteran's multiple sclerosis so VA can decide service connection and assign a disability rating.
Documents the Veteran's muscle injuries by muscle group so VA can decide service connection and assign a disability rating.
Documents the Veteran's narcolepsy so VA can decide service connection and assign a disability rating.
Documents the Veteran's non-degenerative arthritis (inflammatory, autoimmune, crystalline, infectious) and decompression illness so VA can decide service connection and assign a disability rating.
Documents the Veteran's nutritional deficiencies so VA can decide service connection and assign a disability rating.
Documents the Veteran's oral and dental conditions of the mouth, lips and tongue so VA can decide service connection and assign a disability rating.
Documents the Veteran's osteomyelitis so VA can decide service connection and assign a disability rating.
Requests TRICARE authorization for outpatient/ambulatory opioid and substance use disorder treatment.
Documents the Veteran's pancreas conditions so VA can decide service connection and assign a disability rating.
Documents the Veteran's Parkinson's disease and its manifestations so VA can decide service connection and assign a disability rating.
Documents the Veteran's peritoneal adhesions so VA can decide service connection and assign a disability rating.
Documents the Veteran's presumptive infectious diseases from Persian Gulf/Afghanistan service so VA can decide service connection and assign a disability rating.
Documents the Veteran's rectum and anus conditions (hemorrhoids, fistula, sphincter impairment) so VA can decide service connection and assign a disability rating.
Documents the infant condition and 30-day prescription (quantity, frequency) needed for TRICARE coverage of banked donor human milk.
Concurrent review and discharge planning information to continue an authorized RTC stay.
Requests initial TRICARE authorization for psychiatric residential treatment center care for a beneficiary under 21.
Documents the Veteran's seizure disorders (epilepsy) so VA can decide service connection and assign a disability rating.
Documents spina bifida findings in the natural child of a Veteran exposed to herbicides so VA can assign the child's monthly allowance level.
Requests initial TRICARE authorization for Spravato (esketamine) nasal spray for treatment-resistant depression.
Requests continued TRICARE authorization for Spravato (esketamine) treatment.
Documents the Veteran's stomach and duodenal conditions (ulcer disease, gastritis, post-gastrectomy) so VA can decide service connection and assign a disability rating.
Documents the Veteran's systemic lupus erythematosus and other autoimmune diseases so VA can decide service connection and assign a disability rating.
Documents the Veteran's temporomandibular disorders so VA can decide service connection and assign a disability rating.
Documents the Veteran's thyroid and parathyroid conditions so VA can decide service connection and assign a disability rating.
Requests TRICARE authorization for TMS for depression, documenting failed antidepressant trials, psychotherapy history and contraindications.
Prescriber documents active ingredients, diagnosis, route and why a compounded product is needed instead of a commercial product, for TRICARE coverage of compounds.
Prescriber justifies retail-pharmacy fills of drugs in the special non-formulary (non-Federal Ceiling Price) class, which otherwise cost 100% at retail.
Documents the Veteran's tuberculosis so VA can decide service connection and assign a disability rating.
Documents the Veteran's urinary tract conditions including bladder and urethra (voiding dysfunction, incontinence) so VA can decide service connection and assign a disability rating.
State Veterans Home physician certifies the Veteran's diagnoses, functional evaluation and the type of care needed (nursing home, domiciliary or adult day health care) so VA can pay State Home per diem.
VA Form 10-10068bTreating physician documents a family member's diagnosis of one of the 15 covered Camp Lejeune conditions, treatment and dates so VA can decide eligibility for reimbursement under the Camp Lejeune Family Member Program.
Claims total disability insurance benefits / premium waiver under a Government Life Insurance policy; Part II is the attending practitioner's report of diagnosis, findings, treatment and prognosis.
Claims FEGLI accidental dismemberment benefits for loss of a limb or eyesight; the provider documents the accident, loss and dates.
Lets a terminally ill FEGLI enrollee (life expectancy of 9 months or less) receive Basic life insurance as a living benefit; a physician must certify the terminal illness.
Collects the physician's objective medical documentation (history, findings, diagnosis, prognosis, restrictions relative to the position description) for a federal employee's CSRS/FERS disability retirement application.
Physician certifies that a military retiree's adult child is incapable of self-support (and/or of handling finances) because of a mental or physical incapacity, for Survivor Benefit Plan / RSFPP child annuity.
Physician's general medical exam showing a retiring CSRS employee is in good health, required when electing an insurable-interest survivor annuity.
RI 30-10Determines whether an adult child of a federal annuitant or deceased employee is incapable of self-support because of a disability that began before age 18, for survivor annuity and FEHB family coverage.
Records the DOT physical qualification examination of an interstate commercial motor vehicle driver against 49 CFR 391.41 and the examiner's determination.
Certifies that an interstate CMV driver is physically qualified, with any conditions (corrective lenses, hearing aid, exemption, SPE certificate, intracity zone) and an expiration date.
Chain-of-custody and result form for federally regulated (including FMCSA, FAA, FRA, FTA, PHMSA and USCG) urine or oral-fluid drug tests, on which the Medical Review Officer records the verified result.
Merchant mariner's medical and physical examination (conditions, medications, exam, vision, hearing, physical ability) used by the Coast Guard to issue a national/STCW medical certificate under 46 CFR Part 10.
Documents a DOT drug test within the past 185 days, verified by a Medical Review Officer, to meet the merchant mariner periodic drug testing requirement (46 CFR 16.220).
Treating clinician attests that a CMV driver with insulin-treated diabetes has a stable insulin regimen and properly controlled diabetes (glucose monitoring, hypoglycemia, HbA1c, complications).
MCSA-5871Ophthalmologist or optometrist documents visual acuity, fields, color recognition and stability for a driver who cannot meet the vision standard in the worse eye (alternative vision standard, 49 CFR 391.44).
Optional request from the certified medical examiner to the treating provider for diagnosis, monitoring and stability details of a driver's non-insulin-treated diabetes.
MCSA-5895Optional request from the certified medical examiner asking the prescribing provider to list medications and give an opinion on whether they or the treated conditions impair safe CMV operation (49 CFR 391.41(b)(12)).
Treating physician's letter supporting an interstate CMV driver's exemption from the epilepsy/seizure standard (49 CFR 391.41(b)(8)): diagnosis, last seizure, anti-seizure medication history and support to drive.
Physiatrist or orthopedic surgeon assesses a driver's limb loss or impairment, prosthesis/orthosis and precision and power-grasp prehension for an SPE certificate under 49 CFR 391.49.
Short-form medical exam for mariners with only entry-level or staff-officer endorsements (food handlers, or STCW/MLC certificates without watch or lookout duties).
AME's evaluation of a pilot with a single alcohol-related event (DUI/DWI, detainment or arrest) covering history, screening and documentation review, to decide whether to issue or defer.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for osteoarthritis or limited autoimmune arthritis (rheumatoid limited to joints, psoriatic, ankylosing spondylitis) that is stable on an acceptable medication, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for asthma that is stable and well controlled (symptoms and rescue-inhaler use no more than 2 days/times a week, limited steroid bursts, no hospitalization in the last year), based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for hypertension with stable blood pressure control on acceptable antihypertensive medication for at least 7 days and no symptoms or side effects, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for hypothyroidism that is stable on levothyroxine or another acceptable thyroid replacement, without symptoms, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for migraine, tension or cluster headache that is stable on an acceptable regimen with no more than one episode a month and only mild, non-disabling symptoms, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for prediabetes, metabolic syndrome, impaired fasting glucose or insulin resistance (including diabetic medication taken for weight loss) in an applicant whose A1C has never been 6.5% or higher, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for use of medication (including GLP-1/diabetic medication) for overweight or obesity in an applicant whose A1C has never been 6.5% or higher, based on the treating clinician's note.
Treating provider reports A1C, medications, hypoglycemia, complications and stability for a pilot whose diabetes or hyperglycemia is treated with non-insulin medication (AASI).
Eye specialist documents intraocular lens type (monofocal, multifocal, accommodating), visual acuity and complications after cataract surgery or lens replacement.
FAA request (within 90 days) for the treated OSA pilot's sleep study, treatment and compliance documentation, including a completed OSA Treated Status Report from the treating provider.
FAA request that a pilot at risk for OSA obtain a sleep assessment per AASM criteria (and sleep study/treatment if diagnosed) within 90 days.
Treating provider documents OSA treatment, compliance data and symptom resolution for a pilot on CPAP/oral appliance or post-surgery (initial review or AASI renewal).
Treating physician and AME report on symptoms, medications and changes for a pilot or ATCS re-issued under the AASI PATH for anxiety, depression and related conditions.
FAA specification of what a treating provider's clinic note must contain (history, meds, exam, tests, assessment, plan) to be accepted for CACI, AASI and special-issuance decisions.
Prescribing provider documents the weight-loss or prediabetes medication, dose stability, side effects, A1C and BMI for a pilot taking it.
FAA Form 8500-7Eye specialist's report of history, phorias, fusion, pupils, fields, slit-lamp and fundus findings, acuity, IOP, prescription and evaluation for an airman with an eye condition or failed vision screen.
FAA Form 8500-8Records the airman's medical history and the AME's physical examination and certification decision for a first-, second- or third-class FAA medical certificate (14 CFR Part 67).
FAA Form 8700-2State-licensed physician performs a comprehensive exam and declares no known condition that would interfere with safe operation, so a pilot may fly under BasicMed (14 CFR 61.113(i), 68) instead of holding a third-class medical.
Specifies the psychologist's or neuropsychologist's evaluation and report for the ADHD fast track (records review, face-to-face evaluation, findings) within 90 days of the AME exam.
Specifies the in-person HIMS neuropsychologist evaluation and testing report for the ADHD standard track.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for Crohn's disease, ulcerative colitis or other colitis that is stable with no or mild symptoms and no surgery in the last 6 weeks, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for colon/colorectal cancer that is stable with no high-risk features and the airman back to full activity with no treatment needed, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for stable open-angle glaucoma, ocular hypertension/glaucoma suspect, or treated narrow-angle glaucoma diagnosed at 40 or older, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for chronic hepatitis C that is stable, off treatment, without complications and with AST, ALT, albumin and PT within 10% of normal in the last 90 days, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for bladder cancer that is stable, non-muscle-invasive and non-metastatic, with active treatment completed, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for stage 0 / in-situ breast cancer (DCIS, LCIS, Paget disease) with no evidence of disease after completed treatment, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for asymptomatic carotid or vertebral artery stenosis (or surveillance 2+ years after correction) with no clinically significant progression on imaging, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for chronic immune thrombocytopenia more than 12 months from diagnosis with platelets stable above 50,000/microL and no bleeding history or splenectomy, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for stable, asymptomatic chronic kidney disease with eGFR 35 or higher and controlled underlying conditions, with no dialysis or transplant anticipated, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for asymptomatic, observation-only CLL/SLL (Rai 0-1 / Binet A, diagnosed at 40 or older, monitored 5+ years) with acceptable recent labs, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for eosinophilic esophagitis that is well controlled with histologic remission (under 15 eos/hpf) on the most recent endoscopy/biopsy and no fibrostenotic disease, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for stable, non-disabling essential tremor, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for low testosterone/hypogonadism that is stable on replacement therapy with hematocrit 54% or less and no VTE, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for metabolic dysfunction-associated or non-alcoholic steatohepatitis without cirrhosis and with a recent fibrosis score (FIB-4, VCTE or MR elastography) under the FAA thresholds, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for mitral valve repair (mitral valve only) that is stable without anticoagulation other than aspirin, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for polycystic ovarian syndrome that is stable on acceptable medications with cardiovascular risk factors controlled and no diabetes, untreated OSA or depression/anxiety, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for stable, asymptomatic primary hemochromatosis without cardiac, hepatic, CNS, endocrine or joint involvement, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for prostate cancer that is stable, non-metastatic and has completed active treatment, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for mild-to-moderate psoriasis (e.g., plaque, guttate) that is stable with no systemic symptoms or functional limitation, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for renal cancer that is stable with no chemotherapy, recurrence, extracapsular extension, metastasis or paraneoplastic syndrome, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for asymptomatic, stable retained kidney stone(s) unlikely to cause sudden incapacitation, based on the treating clinician's note.
Conditions AMEs Can Issue (CACI) checklist that lets an Aviation Medical Examiner issue a regular airman medical certificate for testicular cancer that is stable, non-metastatic and has completed active treatment, based on the treating clinician's note.
Oncologist summary of stage, treatment, symptoms and labs for a pilot with CLL/SLL (CACI or AASI).
Pulmonologist summary of COPD severity, exacerbations, oxygen use, PFTs and medications for a pilot under AASI.
Cardiologist summary of symptoms, interval events, medications, risk factors and testing for a pilot recertifying under a special issuance for coronary heart disease.
Item-by-item requirements for the endocrinologist's initial comprehensive report, CGM data and renewal reports for an insulin-treated pilot seeking any class under the CGM option.
Specification for the board-certified endocrinologist's initial comprehensive evaluation of an insulin-treated pilot (diabetes history, hypoglycemia, complications, labs, monitoring) within 90 days.
Treating provider documents glucose self-monitoring, hypoglycemia, A1C, complications and regimen for a third-class pilot on insulin certified under the non-CGM option.
Specifies the content of a neurologist's evaluation and report (history, exam, imaging, EEG, medications, prognosis) for pilots with neurologic conditions such as seizure, TBI, migraine or tremor.
HIMS AME's checklist for recertifying a pilot under a drug and alcohol monitoring special issuance (sobriety, monitoring reports, aftercare, evaluations).
HIMS AME's checklist for initial special issuance of a pilot or ATCS treated with an SSRI or other conditionally approved antidepressant.
HIMS AME's checklist for recertifying a pilot or ATCS on an antidepressant special issuance.
HIMS-trained AME's mandatory checklist summarizing treatment, aftercare, monitoring, psychiatric/neuropsychological evaluations and recommendation for a pilot seeking initial special issuance after substance dependence or abuse.
Specifies the treating physician's status report and labs (CD4, viral load, antiretrovirals, cognitive screening) for a pilot with HIV seeking any class of certificate.
Eye specialist documents retinal toxicity screening (fields, OCT etc.) for a pilot taking hydroxychloroquine or chloroquine.
Urologist or endocrinologist summary of testosterone therapy, hematocrit, side effects and VTE history for a pilot on testosterone replacement.
Cardiologist summary of rhythm control, symptoms, CHA2DS2-VASc score and emboli mitigation for a pilot with non-valvular atrial fibrillation or flutter under AASI.
Cardiologist summary of pacemaker indication, device interrogation, dependency and symptoms for a pilot with an implanted pacemaker.
Specifies the cardiology evaluation (history, risk factors, exam, assessment) and lab testing that make up an FAA cardiovascular evaluation.
Records a six-minute walk test done to ATS standards (distance, oxygen saturation, heart rate, symptoms) for a pilot with a cardiac or pulmonary condition.
Specifies the neuropsychological testing and report required after head trauma, stroke, encephalitis, MS or other conditions that may impair cognition.
Specifies the neuropsychological evaluation and testing required for a pilot or ATCS seeking special issuance while on an SSRI/antidepressant.
Specifies the psychiatric and neuropsychological evaluations required for pilots with substance use disorders (HIMS pathway).
Specifies the separate psychiatric and clinical psychological evaluations (records review, interview, testing such as MMPI) required for pilots with mental health conditions.
FAA Form 8500-14Ophthalmologist's report on an airman with glaucoma or ocular hypertension (type, IOP, fields, treatment, stability) used for FAA medical certification and the glaucoma CACI.
States whether the employee is medically able to use the respirator, any limitations, and whether follow-up evaluation is needed, as required by 29 CFR 1910.134(e)(6).
Appendix C to 29 CFR 1910.134Apéndice C: Cuestionario de Evaluación Médico obligado por la OSHA
Mandatory medical questionnaire (or equivalent exam) used by a PLHCP to determine whether an employee is medically able to wear a respirator before fit testing and use.
Limited written opinion on whether hepatitis B vaccination is indicated, or that the employee was informed of post-exposure evaluation results and follow-up needs, under 29 CFR 1910.1030(f)(5).
Attending physician's opinion on whether the employee has conditions increasing risk from hazardous waste work, emergency response or respirator use, with recommended work limitations, under 29 CFR 1910.120(f)(7).
PLHCP's opinion to the employer after a respirable crystalline silica surveillance exam: respirator limitations, specialist referral and exposure limits (with employee authorization), and next exam date.
Pre-placement or periodic medical examination of applicants/employees in federal positions with medical standards or physical requirements, documenting findings that would limit performance of the essential job functions (5 CFR 339).
ILO classification of a chest radiograph for pneumoconiosis outside the CWHSP (e.g. asbestos/silica medical surveillance, clinical or legal reads).
Referral physician evaluates, within 5 days, whether a medical condition precluded a DOT-tested employee from providing a sufficient urine or oral-fluid specimen and recommends a determination to the MRO.
Opinion to the employer within 45 days of a beryllium surveillance exam: exam date, that it met the standard, PPE/respirator limitations, and (with authorization) exposure limits, CBD diagnostic center referral or medical removal.
Examining physician's opinion on conditions increasing risk from lead exposure, recommended protective measures/exposure limits, respirator limits and blood lead results, which drives medical removal protection decisions.
Treating provider documents diagnosis, prognosis, treatment and functional status for asthma, reactive airway disease, COPD or sleep apnea so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for seizures, syncope, stroke, headache or other central nervous system conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for diabetes mellitus or pre-diabetes so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for gastrointestinal conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Catch-all provider statement on a condition not covered by a specific template, with mitigations supporting a medical waiver for wildland fire duties.
Treating provider documents diagnosis, prognosis, treatment and functional status for genitourinary conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for hearing loss or hearing aid use so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for heart disease, murmurs, heart surgery or cardiac implantable devices so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for blood (hematopoietic) disorders so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for hypertension, aneurysm or vascular disease so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for immune system or allergic disorders so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for musculoskeletal or peripheral/central nervous system conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for use of a prosthesis so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Prescriber lists a wildland firefighter's medications and states whether side effects could impair safe performance of fire duties, for Medical Officer review.
Treating provider documents diagnosis, prognosis, treatment and functional status for psychiatric conditions and medications so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for thyroid or other endocrine conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for vision deficits so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Appendix B-I to 29 CFR 1910.1043Standardized respiratory questionnaire used in cotton dust medical surveillance (with spirometry) to detect byssinosis.
Appendix D to 29 CFR 1910.1001Standardized respiratory disease questionnaire required at pre-placement (Part 1) and periodic (Part 2) asbestos medical surveillance exams.
CDC/NIOSH 2.8B Reader's ILO classification of a coal miner's surveillance chest radiograph for pneumoconiosis under the Federal Mine Safety and Health Act.
Pediatric history and physical exam used by State Department MED to medically clear a child family member for an overseas post.
Full history and physical exam used by State Department MED to grant an overseas medical clearance to Foreign Service and other U.S. government employees, applicants and eligible family members.
Provider describes an employee's condition, functional limitations and recommended workplace accommodation (and its duration) so the State Department can decide a reasonable-accommodation request.
Provider's opinion, after a full clearance exam, on whether an individual can live and work in the austere conditions of an ESCAPE (high-threat) post.
Physician's annual certification that a mine rescue team member is physically fit for prolonged mine rescue and recovery work under strenuous conditions (30 CFR 49.7 / 49.17).
Certifies that a reactor operator license applicant or licensed operator meets the medical requirements (ANSI/ANS-3.4 or 15.4) and requests any license conditions recommended by the examining physician.
WH-515Certifies that a person who drives vehicles carrying migrant agricultural workers meets the physical qualifications of 49 CFR 398.3(b) under the Migrant and Seasonal Agricultural Worker Protection Act (MSPA).
Licensed physician attests that the applicant has a permanent physical, mental or sensory impairment that substantially limits one or more major life activities, qualifying them for the free lifetime federal recreation Access Pass.
Certifies that a Medicare patient's non-emergency ambulance transport (scheduled, repetitive or unscheduled) is medically necessary because other transport is contraindicated.
Asks a Medicare Part D plan to cover a drug (prior authorization, formulary, step-therapy, quantity-limit or tiering exception), with a prescriber supporting statement.
Certifies that a patient with diabetes has a qualifying foot condition and is under a comprehensive diabetes plan of care, so Medicare covers depth or custom-molded shoes and inserts.
Certifies a Medicare patient's homebound status and need for skilled home health care and sets out the plan of care (orders, diagnoses, goals) for the certification period.
Aviso anticipado de no cobertura para el beneficiario (ABN)
Warns an Original Medicare patient before a service that Medicare may not pay, so the patient can choose to receive it and accept financial liability.
Standard clinical assessment of every resident of a Medicare/Medicaid-certified nursing home or swing bed, used for care planning, SNF PPS (PDPM) payment and quality measures.
Standard comprehensive assessment of Medicare/Medicaid home health patients at start of care, resumption, follow-up, transfer and discharge, used for payment (PDGM case mix) and quality reporting.
Lets the author of a medical record entry or order attest to a missing or illegible signature so the record can be used in Medicare medical review.
Cover sheet for a DMEPOS prior authorization request (power mobility devices, pressure-reducing support surfaces, lower limb prostheses, orthoses, pneumatic compression devices, manual wheelchairs).
Appeals a Part D plan's denial of drug coverage or payment (first-level appeal), with the prescriber's explanation of medical need.
CMS-2728Documents that a patient has reached end-stage renal disease requiring regular dialysis or a transplant, to establish ESRD Medicare entitlement and register the patient with the ESRD program.
Admission and discharge assessment of Medicare patients in inpatient rehabilitation facilities, used for IRF PPS case-mix payment and the IRF Quality Reporting Program.
Informs a Medicare patient receiving more than 24 hours of observation services that they are an outpatient, not an inpatient, and what that means for cost sharing and SNF coverage.
Standard hospice patient assessment at admission, HOPE update visits and discharge, used for the Hospice Quality Reporting Program.
Requests Medicare prior authorization for blepharoplasty and related eyelid procedures in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for botulinum toxin injections in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for vein ablation in a hospital outpatient department, with answers to the coverage questions.
PAR 457Requests prior authorization under the CMS WISeR Model for selected services (e.g., skin and tissue substitutes, electrical nerve stimulator implantation, knee arthroscopy for osteoarthritis) for Ohio Original Medicare patients.
Requests Medicare prior authorization for facet joint injections, medial branch blocks and radiofrequency ablation in a hospital outpatient department, with answers to the coverage questions.
Lets the treating physician ask the DME MAC for a copy of the prior authorization decision letter for a DMEPOS item ordered for a patient.
Asks the Part D Independent Review Entity to review a plan's adverse redetermination on drug coverage (second-level appeal).
Documents why an admission to a non-participating hospital was a Medicare emergency so that the inpatient or outpatient emergency services can be paid.
CMS-2746Reports the death of a dialysis or kidney transplant patient, with causes of death and treatment status, to the ESRD Medical Information System.
Standard admission, planned/unplanned discharge and expired assessment of patients in long-term care hospitals for the LTCH Quality Reporting Program.
Requests Medicare prior authorization for rhinoplasty in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for panniculectomy in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for implanted spinal neurostimulators in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for cervical fusion with disc removal in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for up to 40 round trips in a 60-day period of repetitive, scheduled non-emergent ambulance transport (e.g., dialysis, wound care).
Requests Medicare prior authorization for blepharoplasty performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for vein ablation performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for rhinoplasty performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for panniculectomy performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for botulinum toxin injections performed in an ambulatory surgical center (Ohio).
DoDEA Form 1307Physician and dentist certify that a child enrolling in DoDEA's Sure Start pre-kindergarten program is in satisfactory health, free of communicable disease, and up to date on immunizations.
NIH Publication No. 20-HL-5251Green/yellow/red-zone written asthma plan listing daily controller and quick-relief medicines and when to seek emergency care, aligned with the 2020 Focused Updates to the Asthma Management Guidelines.
National model death certificate whose medical certification section (cause of death, manner, injury details) every state certificate and EDRS follows.
NCHS guidance with instructions and worked examples for completing the medical certification (cause-of-death) section of the death certificate.
Collects clinical, MRI and laboratory details on a suspected acute flaccid myelitis case for classification by CDC.
National surveillance report of a Hansen's disease (leprosy) case: demographics, exposure (armadillo contact, residence history), treatment, disabilities and household contacts.
National surveillance report of a malaria case: travel, chemoprophylaxis, species, treatment and adverse events.
Case report for spotted fever rickettsiosis (incl. RMSF), anaplasmosis and ehrlichiosis with clinical and laboratory details.
Reports an adverse event after vaccination; providers are legally required to report events on the VAERS Table of Reportable Events and certain EUA/monkeypox vaccine events.
CDC 50.42AReports HIV infection or AIDS in a patient aged 13 or older at diagnosis to the health department for national HIV surveillance (eHARS).
Reports HIV infection, AIDS, perinatal HIV exposure or seroreversion in a child under 13 to the health department for national HIV surveillance (eHARS).
CDC 55.54Surveillance case report of Kawasaki syndrome: clinical criteria, coronary findings and IVIG treatment.
Health professional's voluntary report of an adverse event, product problem, or medication error involving a drug, biologic, device, dietary supplement, cosmetic or other FDA-regulated product.
A professional attests that the applicant's combined hearing and vision loss meets the NDBEDP definition of deaf-blind so the applicant can receive free communication technology.
Physician-signed diagnosis of the relevant impairment(s), used when an individual without SSI/SSDI qualifies to open a tax-advantaged ABLE (529A) account by disability certification.
Ophthalmologist or optometrist certifies that the taxpayer's best-eye corrected vision is no better than 20/200 or the visual field is 20 degrees or less (and whether it will improve), supporting the additional standard deduction for blindness.
Eye doctor certifies vision no better than 20/200 in the better eye with correction, or a visual field of 20 degrees or less, so the taxpayer can claim the additional standard deduction for blindness.
Physician certifies that a taxpayer under 65 was permanently and totally disabled on retirement (or 1/1/1976-77) so the taxpayer can claim the Credit for the Elderly or the Disabled.
Solicitud de servicio gratuito de biblioteca
Enrolls a person with blindness, low vision, a physical disability or a reading disability in the free NLS braille and talking-book service; a certifying authority confirms eligibility.
Lists the 9/11-related conditions a private treating physician has diagnosed (onset and diagnosis dates) with supporting records, so the VCF can verify eligibility for claimants using the Private Physician process instead of the WTC Health Program.
Medical summary of a military family member's special medical, developmental or behavioral health needs, used to identify and enroll them in the EFMP and screen them for overseas/remote assignments.
Summarizes a military child's early intervention (IFSP) or special education (IEP) eligibility and related services for EFMP enrollment and overseas travel screening.
Treating physician (as sponsor) requests FDA authorization to treat a single patient with an investigational drug or biologic outside a clinical trial (compassionate use), including emergency requests.
Documents the immigration medical exam (communicable diseases, physical/mental disorders with harmful behavior, drug abuse, vaccinations) required for adjustment of status to permanent residence.
Waiver of inadmissibility; for a Class A tuberculosis condition, the local health department physician certifies that the applicant will report for TB examination and treatment after arrival.
Certifies that a naturalization applicant's physical or developmental disability or mental impairment prevents them from meeting the English and/or civics test requirements.
OMB No. 1845-0065Discharges Direct, FFEL and Perkins student loans and TEACH Grant service obligations when an authorized medical professional certifies the borrower cannot engage in substantial gainful activity because of an impairment expected to result in death or lasting 60+ months.
OMB No. 1845-0011Defers federal student loan payments during cancer treatment and for 6 months after; the physician certifies the treatment dates.
OMB No. 1845-0011Defers federal student loan payments while the borrower is in a licensed vocational, drug-abuse, mental-health or alcohol-abuse rehabilitation program; the program certifies enrollment and dates.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The Total and Permanent Disability Discharge Application (OMB 1845-0065). An MD, DO, NP, PA or certified psychologist licensed in the U.S. certifies that the borrower cannot engage in substantial gainful activity because of an impairment expected to result in death or to last at least 60 months. FSA prefers electronic signing through a DocuSign email. On paper, every box must be answered, and the borrower must submit within 90 days of the provider's signature.
An MD, DO or clinical psychologist licensed in the U.S. The N-648 certifies that a physical or developmental disability or mental impairment keeps a naturalization applicant from meeting the English and/or civics test requirements. The exam must be in person, or by real-time telehealth where state law allows. The applicant files it with Form N-400 or later. USCIS charges no filing fee, and the clinician may charge for the exam and paperwork.
Only a USCIS-designated civil surgeon. The I-693 records the exam for communicable diseases, physical or mental disorders with harmful behavior, drug abuse and vaccinations, required for adjustment of status to permanent residence. The civil surgeon seals it in an envelope for the applicant, who files it with Form I-485. Only the 01/20/25 edition is accepted for civil-surgeon signatures on or after July 3, 2025, and unsigned forms are rejected.
The certified medical examiner keeps the MCSA-5875 exam report on file for at least 3 years and uploads the results to FMCSA's National Registry. The driver gets the MCSA-5876 Medical Examiner's Certificate, valid for up to 24 months, or less when a condition needs monitoring. Related federal forms include the MCSA-5870 for insulin-treated diabetes, the MCSA-5871 vision evaluation report and the MCSA-5895 driver medication form.