Attachment 3 - Medical Review Form (pdf)
Text Version of Form
The Serve Illinois Commission is requesting disclosure of information that is necessary to assist in evaluating a reasonable accommodation request. Disclosure of this information is VOLUNTARY.
*Members/applicants are responsible for having this form completed by Physician and forwarded to your Program Director.
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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