FDNY Medical Documentation Form (HR-07-03)
Plain answers about FDNY form HR-07-03, from Certicare. The provider's section is completed and signed by a state-licensed provider after an online evaluation, where the evaluation supports it, for $49. For FDNY EMS and civilian staff. Uniformed firefighters: see the section on BHS below.
What is the FDNY Medical Documentation Form (HR-07-03)?
It's the Fire Department's own form for documenting a medical absence. The top names the Fire Department of the City of New York, and the form is titled Medical Documentation Form, number HR-07-03, Rev 06/08. If yours matches, you're on the right page.
The form has three parts, and only one of them needs a health care provider. That's the part a state-licensed provider completes through Certicare, where the evaluation supports it. When the form is due is printed on the form itself; if it's unclear, ask your supervisor.
$49, usually within 24 hours after we have everything needed.
Who fills out each part of the form?
You fill out the top. It asks for your name, title, shield number if you have one, your bureau or department, the nature of the absence, and your signature and date.
The middle is the provider's section. A health care provider or diagnostic center completes it, not the employee.
The bottom is completed by your unit supervisor, who records when the documentation was received.
- TopYou
- MiddleA health care providerCompleted through Certicare
- BottomYour unit supervisor
What does the provider's section ask for?
Details about the provider: telephone, address, signature, and license or registration number, plus the date of service. The provider's license number goes on the form itself.
Then three dates about you, under "Complete if patient is employee": the date you were seen, the period you were unable to perform your duties (from and to), and the date you may return to work.
- Provider's telephone and address
- Signature and license or registration number
- Date of service
- Date you were seen
- Dates you were unable to work
- Date you may return to work
The form also has a block for when the patient is a family member. The provider completes the employee block only, for your own health condition.
Can a provider complete it online?
Yes, where the evaluation supports it. You answer an online intake, usually no appointment to book, and a state-licensed provider reviews your answers. A provider may follow up for more detail before deciding.
Then the provider completes and signs the provider's section of your HR-07-03. An evaluation is not a promise of a signature; the provider signs only what it supports.
- 1
Online intake
- 2
Evaluation by a state-licensed provider
- 3
Provider's section completed and signed, where the evaluation supports it
The form says it may be subject to authentication and verification. FDNY decides whether to accept it.
Certicare is not affiliated with or endorsed by the Fire Department of the City of New York (FDNY), the City of New York, or any union. This page is general information about the leave process, not legal advice.
What if you're a firefighter?
Then this service isn't for you. It is not suitable for uniformed firefighters.
When a uniformed firefighter goes sick, it runs through the FDNY Bureau of Health Services (BHS), and BHS does the examination. A note from an outside provider doesn't replace a BHS visit.
Who completes the provider's section for you?
If the provider already treating you will complete the form, that's the simplest route. Certicare is for when that isn't available, or not in time.
It runs through Certicare's $49 medical leave forms service. The provider's section is completed and signed by a state-licensed provider, after an online evaluation, on the HR-07-03 you already have.
Upload your HR-07-03 with the intake. The completed form comes back to you by email, and you hand it in.
$49 covers one leave case: the clinical review, the forms that case needs, and any follow-up your employer or leave administrator asks for afterward.
Secure online intake. Your information is reviewed by Certicare and is not sent to FDNY without your authorization.
HIPAA-compliantWrite to hello@certicare.org with any question before you start.
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