Try for free

USFS Fire Medical General Medical Provider Template

The Forest Service Fire Medical Qualifications Program uses this catch-all template when a fire employee's flagged condition doesn't have its own condition-specific form. The treating provider gives the diagnosis, medications, stability, relapses in the past five years, related surgeries, any concern about dehydration, exertional heat illness or rhabdomyolysis, and any restrictions on fire duties. Medical Officers use it to weigh qualification or a waiver.

Who completes it

The employee completes Part A (name, date of birth, home unit and light, moderate or arduous fitness level), which also authorizes release to Forest Service Medical Officers. The treating provider (MD, DO, NP, PA or other) completes Part B as applicable and signs it with an office stamp.

Submitting and payment

How to submit it
Fax the completed form to the Fire Medical Qualifications Program office as printed on the form; the program also receives documents through the employee's eMedical account.
Who pays
When a Medical Officer requests more medical information, the employee must obtain, pay for and supply it under 5 CFR 339.304(c).

Good to know

  • Check first for a condition-specific template: the program posts forms for hypertension, immune and allergic disorders, musculoskeletal, prosthetic, psychiatric, thyroid, vision and other conditions.
  • For relapses in the past five years, describe how often they occur, whether they are debilitating, their effects and the body part affected.
  • The restriction question assumes 16-hour days for up to 21 days, heat over 100°F or cold below 32°F, altitude over 5,000 feet, smoke, irregular meals and sleep.
  • The program also posts a Change in Medical Status form for employees and a Provider Medication Statement for providers.

Get the official form

Download the current version from the source each time; forms change without notice.

USDA Forest Service: Fire Medical Qualifications Program - General Medical Provider Template

Official pagePDF

How this list is checked

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.

Frequently asked questions

When should a provider use the Forest Service General Medical Provider Template?

When the employee's condition isn't covered by one of the program's condition-specific templates, such as those for asthma, diabetes, heart disease or vision. It collects the same core information: diagnosis, medications, stability, recurrences, surgeries and any restrictions on fire duties.

What restrictions question is on the Forest Service provider template?

Every provider is asked whether the employee has restrictions for fire duties that may run 16 hours a day for up to 21 days, in heat above 100°F or cold below 32°F, altitude over 5,000 feet, constant smoke and dust, irregular meals and sleep, and with definitive care more than an hour away.

Who decides a Forest Service medical waiver?

Only a Forest Service Medical Officer. The treating provider documents the condition on this template, and the Medical Officer reviews it with the rest of the file. A waiver can only be considered when enough information is obtained, and it applies to conditions that are static and stable.