12/15/25, 10:11 AM Kaiser Permanente - Letter Details
Date printed: 12/15/2025
Kaiser Permanente Member name: Rajan Gill
Date of birth: 1/13/1999
MRN: 110012830057
LANE, FRANCESCA MARIE (D.O.)
1900 DRESDEN DRIVE
LINCOLN CA 95648-8803
916-543-5400
Patient Name: Gill,Rajan
Encounter Date: 12/15/2025
Auth ID: 32624263140.1
Please see below for this health care provider's directives and information relating to this encounter.
Student Status Report
Modified Activity
The patient is excused from class from 12/15/2025 through 1/13/2026 due to initiation of new medication and is
advised to rest and monitor for any potential side effects or adjustments.
If modified activity is not accommodated by the employer then this patient is considered temporarily and
totally disabled from their regular work for the designated time and a separate off work order is not
required.
This patient's activity is modified as follows:
* Drive: Not at all.
This form has been electronically signed by LANE, FRANCESCA MARIE (D.O.)
This form contains your private health information that you may choose to release to another party,
therefore please review for accuracy.
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