FOR SOCIAL SECURITY AND STATUTORY SICK PAY PURPOSES ONLY
NOTES ABOUT THIS FORM: This is a new MED3 form for a pilot project to evaluate new methods for issuing medical statements. There is no change from the existing MED3 form and it should be used in the same way and for the same purpose
THE PATIENT can use this form either:
1.  For Statutory Sick Pay (SSP) purposes – fill in Part A overleaf. Also fill in Part B if the doctor has given you a date to resume work. Give or send the completed form to your employer.
2.  For Social Security purposes –
To continue a claim for State benefit fill in Parts A and C of the form overleaf. Also fill in Part B if the doctor has given you a date to resume work. Sign and date the form and send it to Jobcentre Plus to avoid losing benefit.
NOTE: To start a claim for State benefit, the PATIENT must call 0800 055 6688 (8am – 6pm Monday to Friday). If there are speech or hearing difficulties use a textphone on 0800 023 4888.
Information regarding the pilot project for which this form is being used can be found at:
www.hmrc.gov.uk/employers/med-cert-pilot.htm.
Doctor’s Statement
In confidence to:
«patient_title» «patient_forename» «patient_surname»
I examined you today and advised you that
(a) You need not refrain from work / (b) You should refrain from work
For: «patient_for»
OR until: «patient_until»
Diagnosis of your disorder causing absence from work: «diagnosis»
Doctor’s remarks: «remarks»
Doctor’s signature Date of signing 14/10/2008
«doctor_name»
«doctor_address1»
«doctor_address2»
«doctor_postcode»
Form MED3 - «unique_id»
If you cannot fill this in yourself ask someone else to do so and sign it for you
A. TO BE COMPLETED IN ALL CASES – PLEASE USE BLOCK LETTERS
Surname / « patient_title» / «patient_surname»
First names / «patient_forename»
Present address / «patient_address1»
«patient_address2»
Postcode / «patient_postcode»
Date of birth / «dob_date» / «dob_month» / «dob_year»
National Insurance No.
Works or Clock Number or Department
B. If the doctor has given you a date to resume work
DAY MONTH YEAR
Date you intend to start (or seek) work for any employer or as a self-employed person
For night shift workers only:
Shift will begin at / Time am/pm
And end next day at / Time am/pm
C. FOR STATE BENEFIT CLAIMANTS ONLY
Full name and address of employer (if employed)
DECLARATION
I understand that if I give incorrect or incomplete information action may be taken against me.
I declare that because of incapacity I have not worked since the date of my last claim.
I also declare that my circumstances and those of my dependants are and have been as last stated (if there has been a change cross out this declaration and attach a signed and dated statement of the new facts).
I declare that the information I have given on this form is correct and complete.
I agree that the Department for Work and Pensions or an approved healthcare professional acting on their behalf may get in touch with my doctor so that they may give the Department for Work and Pensions any information needed to deal with this claim and any request to look at this claim again.
Signature…………………………………………………Date…………………..
If you have signed this form for someone else please tick here
«unique_id»