Verification Of Disability {D-248}

SDSC D-248 (New 1/10) VERIFICATION OF DISABILITY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 CENTRAL DIVISION, COUNTY COURTHOUSE, 220 W. BROADWAY, SAN DIEGO, CA 92101 CENTRAL DIVISION, FAMILY COURT, 1555 6TH AVE., SAN DIEGO, CA 92101 CENTRAL DIVISION, MADGE BRADLEY, 1409 4TH AVE., SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 NORTH COUN TY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 PLAINTIFF(S)/ PETITIONER(S) DEFENDANT(S)/ RESPONDENT(S) CASE NUMBER VERIFICATION OF DISABILITY DCSS NUMBER Authorization for Release of Information Patient Name: Date of Birth: I hereby authorize my doctor and/or my doctor222s designee to release medical information necessary to complete the Verification of Disability portion of this form set forth below. The purpose of this authorization is so that appropriate child and/or spousal support may be determined in my case(s). Date: Patient Signature: Verification of Disability by Doctor The nature of the patient222s disability/injury that limits his/her employment is: . The patient is under my care and has been since . The patient cannot work can work with the following limitations: . The patient should be able to return to work on . The patient222s next scheduled appointment with me is I declare under penalty of perjury pursuant to the laws of the State of California that the above is true and correct. Date: Signature: Printed Name and Title: Address: Telephone Number: Medical License Number: American LegalNet, Inc. www.FormsWorkFlow.com