The TDI 3P form is a vital document used by the Rhode Island Department of Labor and Training to certify an individual's temporary disability. This form requires detailed information from a qualified healthcare provider, affirming the claimant's medical condition and its impact on their ability to work. If you need to fill out this important form, please click the button below.
The TDI 3P form is a crucial document for individuals seeking Temporary Disability Insurance (TDI) benefits in Rhode Island. This form serves as a statement from a qualified healthcare provider, typically a physician or medical practitioner, regarding a claimant's medical condition and ability to work. It requires detailed information about the claimant, including their diagnosis, functional limitations, and the cause of their illness or injury. The healthcare provider must also indicate any complications that could affect recovery and provide specific dates related to the claimant's treatment and ability to work. Additionally, the form includes sections for certifying the duration of the disability and whether the claimant can return to work, either full-time or part-time. This comprehensive information is essential for the TDI program to assess eligibility and determine the appropriate benefits for individuals unable to work due to medical reasons. Understanding how to fill out this form correctly can significantly impact the approval process for TDI benefits, making it an important step for those navigating temporary disability claims.
After gathering the necessary information, follow these steps to complete the TDI 3P form accurately. Ensure all sections are filled out completely to avoid delays in processing.
After completing the form, review it for accuracy. Mail it to the address provided or fax it to the designated number. Ensure that any costs associated with completing the form are understood, as they are the responsibility of the claimant.
When dealing with the TDI 3P form, there are several other documents that may be necessary to support your application or claim. These documents help provide additional context and information regarding your situation. Below is a list of commonly used forms and documents that are often associated with the TDI 3P form.
Gathering these documents can streamline your application process and help ensure that all necessary information is presented. It is important to keep copies of everything you submit and to follow up as needed to ensure your claim is processed smoothly. If you have any questions or need assistance, resources are available to help guide you through this process.
What is the TDI 3P form?
The TDI 3P form is a document used in Rhode Island for Temporary Disability Insurance. It serves as a statement from a qualified healthcare provider about a patient’s ability to work due to illness or injury. This form is essential for individuals seeking disability benefits while they are unable to perform their job duties.
Who needs to fill out the TDI 3P form?
The form must be completed by a qualified healthcare provider, such as a physician or medical practitioner. They provide necessary medical information regarding the patient’s diagnosis, functional limitations, and the expected duration of their inability to work.
What information is required on the TDI 3P form?
The TDI 3P form requires several key pieces of information, including the patient's name, Social Security number, diagnosis, functional limitations, cause of illness or injury, and any complications affecting recovery. Additionally, the healthcare provider must indicate the dates of examination and certify the patient's inability to work.
How does the healthcare provider certify the patient’s inability to work?
The healthcare provider certifies the patient's inability to work by filling out specific sections of the form. They must provide the date from which the patient is considered unable to work and estimate how many weeks this condition is expected to last. Their signature confirms the accuracy of the information provided.
Can a patient receive unemployment benefits while on TDI?
If a patient is unable to perform their regular job duties and does not have a job to return to, they may be eligible for unemployment benefits. The healthcare provider should indicate this on the form if applicable.
What happens if the healthcare provider makes a false statement on the form?
Making a false statement or failing to disclose important facts on the TDI 3P form can lead to serious consequences. The healthcare provider certifies under penalty of perjury that the information is true. If found guilty of fraud, they could face fines or imprisonment.
How should the completed TDI 3P form be submitted?
The completed form should be mailed or faxed to the Rhode Island Department of Labor and Training at the address or fax number provided on the form. It is important to ensure that all information is accurate and complete before submission.
Is there a cost associated with completing the TDI 3P form?
Yes, any costs incurred for copying medical records or completing the TDI 3P form are the responsibility of the claimant. The TDI program does not cover these expenses.
What if the patient is pregnant?
If the patient is pregnant, the form requires specific information related to the pregnancy, including the expected delivery date and any complications. The healthcare provider will also need to indicate whether the patient can work pending delivery.
When filling out the TDI 3P form, there are important guidelines to follow to ensure accuracy and compliance. Below is a list of dos and don'ts to consider.
When filling out the TDI 3P form, several important aspects should be kept in mind to ensure a smooth process. Here are key takeaways that can guide both healthcare providers and claimants:
By following these guidelines, both healthcare providers and claimants can navigate the TDI 3P form process more effectively, ensuring that all necessary information is provided for a timely review.
TDI–3P (7-1-12)
RHODE ISLAND DEPARTMENT OF LABOR AND TRAINING
TEMPORARY DISABILITY INSURANCE DIVISION
PO BOX 20100 CRANSTON, RHODE ISLAND 02920-0941
Tel.# for Physician offices only: (401) 462-8447 Tel.# for patients: 401-462-8420 FAX # (401) 462-8466
STATEMENT OF QUALIFIED HEALTHCARE PROVIDER (QHP)
(Physician or Medical Practitioner)
Printed from Website
Treating Physician or Medical Practitioner’s Name:
Claimant’s S.S. #: ________-________-___________
___________________________________________
Claimant’s Name: ____________________________
Customer’s Address:
Treating Physician or Medical Practitioner’s Address:
Customer’s Phone #:___________________________
Email Address:________________________________
Date of Birth: ___________/________ /___________
_____________________BELOW THIS LINE MUST BE COMPLED BY A PHYSICIAN OR MEDICAL PRACTITIONER ONLY_____________________
_______________________________________________________________________________________________________________________________________
If the above claimant is able to perform their regular and customary work while being treated for the current illness/injury and he/she does not have a job to return to, please indicate a recovery date. He/She may be eligible for Unemployment Insurance benefits.
1.Diagnosis (not symptoms):______________________________________ ICD9-CM Code ____________(Required)
2.What are the functional limitations, if any, preventing him/her from performing customary work duties?
________________________________________________________________________________________________________
3. Cause of illness/injury:
Work related
Illness
Pregnancy
Auto accident
Other:_____________________
If work related, please indicate the name of the insurance carrier being billed. __________________________________________
4.Any Complications slowing recovery:__________________________________________________________________________
5.Provide date from which you are certifying he/she as functionally “unable to work”. ________/______/_______
NOTE: this date must occur the week prior to, the week of, or the week following your physical examination of the claimant. (Diagnoses via telephone calls are not permitted by TDI law.)
6.
Certifying examination date for current illness: ____/____/___
Most recent examination date for current illness:___/___/___
7.
Was patient hospitalized for this illness/injury?
yes
no
Hospital name: ________________________________ Date Admitted:_____/_____/_____Date Discharged: ____/_____/_____
Did patient have surgery?
If yes, what type of surgery:____________________________________________________ Date of surgery: ____/_____/_____
8 .
If Pregnancy, expected delivery date:
____/_____/_____
Actual delivery date: ____/_____/_____
Type of delivery:
Vaginal
C-section
Please provide any pregnancy complications; Pre
or Post
partum:____________________________________________
9.
Is patient able to work pending surgery or delivery?
Full time work
Part time work
No work
10.
Based on the information provided, it is your medical opinion that, the above mentioned patient will be:
UNABLE TO WORK AS OF THIS DATE:(see #5) ___/___/___ FOR THIS NUMBER OF WEEK(S):_____(How many weeks)
11.
Is patient able to return to customary work on a full time basis?
no If yes, as of what date: ____/_____/______
12.
Is patient able to return to less then his/her normal hour of work?
If yes, as of what date and for how many hours per day & week? Date: ___/___/____Hours per day:_____ Hours per week:_____
For how many weeks is patient able to work less than his/her normal hours?________________(Weeks).
Having considered the patient’s regular and customary work, I certify under penalty of perjury that, based on my in-office examination, this medical certification truly describes the patient’s disability (if any) and the estimated duration thereof. I also understand that if I make a false statement or fail to disclose facts, with intent to defraud the TDI Program, I shall upon conviction be punished to the full extent allowed by law including fine and /or imprisonment.
I further certify that I am a ______________________________________-_____________________________License #:____________
(Type of Qualified Healthcare Provider-QHP)(Specialty)
QHP’s Name:_____________________________________________ Phone #:______________________Fax#:_____________________
Signature:_________________________________________________________________________________ Date:________________
Please note: TDI is not responsible for costs incurred for copying medical records or completing medical forms. Any costs incurred
is the responsibility of the claimant.
Please mail to above address or fax to: (401) 462-8466
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Understanding the TDI 3P form can be challenging, and several misconceptions often arise. Here are five common misunderstandings:
Being informed about these misconceptions can help ensure a smoother application process for those seeking Temporary Disability Insurance benefits. Understanding the form's requirements and the role of healthcare providers is crucial for success.