Medical Certificates

(Revised 2016 – AMA Guide)

Medical Certificates Required By Third Parties:

• Certification of a patient’s illness
• Certification of a patient’s fitness
• Certification of a patient’s recovery from a medical condition
• Certifying illness to show inability to attend work
• Certifying attendance at a medical appointment (for the patient or their carer)

Responsibilities of the Doctor:

• Assess eligibility for a medical certificate based on:
  • Patient’s history (reported and accepted by the doctor)
  • Examination findings
• Ethical, professional, and legal obligations to be:
  • Honest
  • Impartial
  • Trustworthy
• Maintain confidentiality, disclosing information only with patient’s consent or as required by law
• Verify third party identity if contacted about a certificate’s veracity; provide no additional information without patient consent
• Record in patient’s medical record:
  • Information forming the basis of the certificate
  • Copy of the certificate or its content
  • Patient’s consent (or refusal) for additional information disclosure
• Issue certificates for a clinically justifiable period

Legal Considerations:

• Medical certificates are legal documents
• False, misleading, or inaccurate certificates can result in disciplinary action or civil/criminal legal action

Other Types of Medical Certificates:

• Fitness Certificate:
  • Certifies a patient’s fitness for a defined activity
  • Relevant information includes type, duration, intensity, frequency, and environmental conditions of the activity
• Certificate of Recovery:
  • Certifies a patient has sufficiently recovered to resume activities without risk

Responsibilities of the Patient:

• Consult doctor timely when requesting a certificate
• Provide honest health information and reasons for the certificate request
• Ensure third party requirements for leave are met
• Do not alter the certificate

Responsibilities of Third Parties:

• Inform the patient of sick leave requirements
• Respect the confidentiality of medical details
• Accept doctor’s certificate of unfitness as sufficient

Certificate Requirements:

• Name and address of the doctor
• Name of the patient
• Date of examination
• Date of certificate issuance
• Dates the patient was unfit for attendance
• Diagnosis usually not required unless with patient’s express consent
• Legible and understandable (avoid medical jargon)
• Written on appropriate stationery

Date of Certificate:

• Must be dated the day written
• No backdating allowed
• Consider circumstances before certifying illness prior to examination date

When a Certificate Should Not Be Provided:

• Insufficient evidence of lack of fitness
• Avoid issuing to close personal relationships

Carer’s Certificates:

• Required for time off to care for a sick or injured individual
• Issued only by the patient’s treating doctor
• Ensures the patient needs or needed care, not determining who qualifies as a carer