IMG Certificate of medical condition / attending physician's statement 2026: editable PDF
IMG Certificate of medical condition / attending physician's statement: 68 fields. Itaca fills them for you.
Field by field, with your patient's data and clinical history. You just review and sign.
- Insurer
- IMG
- Form fields
- 68
- Type
- Medical certificate
- Edition
- MAP CODE 0924
From record to form, in three steps
The same flow works for every IMG patient: don't retype what's already in the record.
- 1
Choose the patient
Open this IMG form in Itaca and select who it's for.
- 2
Itaca fills the form
It takes the data and clinical history from the patient's visits and documents.
- 3
Review, sign and send
Correct anything that needs it, download the PDF and sign it.
Sections in this form
- Certificate of Medical Condition / Medical Provider's Statement
- Attending physician's statement
- List all dates of treatment and services for this condition
- Hospitalization
- Attending physician's statement—must be completed and signed by the physician
- Condición Médica y Restricciones
- Declaración y Firma del Médico
- Physician Information and Certification
Blank IMG Certificate of medical condition / attending physician's statement
Fillable PDF with 68 fields. If IMG publishes a new version, that version prevails.
Download blank PDFWhat if you skipped the typing?
Itaca fills the form by reading the record. You review, sign and send.
Frequently asked questions
What record data does Itaca use to fill it?
The patient's details, visits, documents and test results already on record. Anything that isn't in the record stays blank for you to complete.
Can I use my own form if IMG changes it?
Yes. You can upload any fillable PDF to Itaca and use it as a template for your practice or organization.
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Your next IMG patient won't take up your afternoon.
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