Medical certificates and reports
July 2004
Completing the statutory certificates
The doctor who has clinical responsibility for the patient’s treatment should provide the certificate or report. For instance, hospital doctors should provide any certificates such as form Med 3 required for hospital in-patients, and out-patients, for whose treatment they have clinical responsibility.
Only a ‘registered medical practitioner’ can issue official statements of a person’s incapacity for work. The opinion of a health care professional (dentist, physiotherapist) would clearly be persuasive to an employer or benefit decision maker but would need to be provided on a certificate other than an official statement. The certificate should clearly identify the name, address and speciality of the practitioner. Equally, although there is increasing skill mix within the primary care team, only a doctor can fill in the official statement.
GPs should be familiar with the guidance issued by the DWP about providing ‘back-dated’ statements.
Med 3 and Med 4 statements – you must examine the patient on the day, or the day before, you issue these statements. They cannot be ‘back-dated.’
Med 5 statement – can be used to supply evidence of incapacity for an earlier period but you must either:
- base your advice on examination of your patient on a previous occasion providing you are sure that you would have advised your patient to refrain from work from the date of that earlier examination for the entire period of the certificate or,
- base your advice on a report from another doctor issued less than one month previously and issue form Med 5 for a forward period up to one month.
Issue form Med 3 for an appropriate forward period in keeping with your clinical findings from the date of your current examination with a note in the remarks section stating, for example,
‘Has been unfit since…(date)….’ or
‘The above diagnosis has been present since birth’….or
‘The above condition has been present since….(date)….’
Retrospective information should only be provided where contemporaneous notes exist. GPs are reminded that they might be asked to provide further information to substantiate certification in such circumstances.
GPs are not allowed to issue duplicate certificates relating to social security claims. An exception is where replacements are required for forms which have been lost. These should be marked ‘duplicate’.
GPs are not obliged to issue Med 3 forms for periods of sickness lasting 7 days or less.