Administrative — Medical Clearance Letter Template
The Medical Clearance Letter Template is designed for physicians and healthcare providers completing documentation to clear patients for specific activities, procedures, or participation in programs. This template provides the structured format required for various clearance scenarios and includes sections for patient demographics, medical assessment, clearance determination, restrictions or accommodations if needed, and provider attestation. This template streamlines the clearance documentation process, ensures clear communication, supports appropriate activity participation, and protects provider time by standardizing documentation. The structured format is adaptable for fitness for duty, activity clearance, procedure clearance, and other clearance scenarios. Ideal for primary care practices, occupational medicine practices, and practices frequently completing clearance documentation.
Template
Letter Header
Provider name, credentials, practice name
Address, phone, fax, NPI
Date
Patient Information
Patient name, DOB
Clearance requested for: [Activity, procedure, program]
Medical Assessment
Current medical conditions: [List]
Medications: [List]
Allergies: [List]
Physical examination: [Relevant findings]
Functional assessment: [If applicable]
Clearance Determination
☐ Cleared without restrictions
☐ Cleared with restrictions: [Specify]
☐ Cleared with accommodations: [Specify]
☐ Not cleared: [Reason]
Restrictions/Accommodations (If Applicable)
[Specific restrictions or accommodations needed]
Provider Attestation
I certify that the above information is accurate and that this patient is [cleared / not cleared] for [activity/procedure] as specified above.
Provider Signature
[Signature, credentials, date]
💡 Tip: Click anywhere to edit. Changes are temporary.
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