Family And Medical Leave Act (Fmla) Medical Certification Form Page 2
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9Please complete and return to:
Verizon
The Absence Reporting Center
500 Summit Lake Drive, 3rd Floor
Valhalla, NY 10595
Fax: 877-786-4500
Phone: 1-855- 814-9344
Family and Medical Leave Act (FMLA) Medical Certification Form
FMLA is a federal law that guarantees “eligible” employees up to twelve (12) work weeks of job-
protected absence for certain family and medical reasons. You are eligible to request an FMLA absence
if you have worked for the company for at least one year, worked a minimum of 1250 hours over the
previous twelve (12) months, and need to be absent for one of the following reasons:
A serious health condition that makes you unable to perform any one of the essential functions of
your job.
To care for your immediate family member (spouse, child, or parent) who has a serious health
condition.
To care for your newborn child, or placement of an adopted or foster child.
Family and Medical Leave Act Definitions for Health Care Providers
as defined by the Department of Labor’s Regulations
Activities of daily living (ADLs): Examples include adaptive activities such as caring appropriately for
one’s grooming and hygiene, bathing, dressing and eating.
Health Care Provider (HCP): Authorized health care providers include any of the following who are
authorized to practice under State law, and who are practicing within the scope of that practice: doctors
of medicine or osteopathy, podiatrists, dentists, clinical psychologists, optometrists and chiropractors,
nurse practitioners, nurse-midwives, clinical social workers, and any other person determined by the
Secretary of Labor to be capable of providing health care services.
Incapacity: The inability to work or perform regular daily activities due to the patient's serious health
condition, treatment for that condition, or recovery from that condition.
Instrumental activities of daily living (IADLs): Activities include cooking, cleaning, shopping, paying
bills, maintaining a residence, using a post office and telephone.
Regimen of Continuing Treatment: Treatment including, for example, a course of prescription
medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health
condition. A regimen of treatment does not include the taking of over-the-counter medications such as
aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that
can be initiated without a visit to a health care provider.
Please fax the completed forms to the correct processing center.
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