Family And Medical Leave Act (Fmla) Medical Certification Form Page 3
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9Family and Medical Leave Act Definitions for Health Care Providers (Cont’d)
as defined by the Department of Labor’s Regulations
Serious Health Condition: An illness, injury, impairment, or physical or mental condition that meets one
of the following criteria:
1. Hospital Care: Inpatient care (e.g. an overnight stay) in a hospital, hospice, or residential medical
care facility, including any period of incapacity or subsequent treatment in connection with or
consequent to such inpatient care.
2. Absence Plus Treatment (Acute): A period of incapacity of more than three consecutive calendar
days (including any subsequent treatment or period of incapacity relating to the same condition), that
also involves:
A. Treatment two or more times, within 30 days of the first day of incapacity, unless extenuating
circumstances exist by an HCP or by a nurse or physician's assistant under direct supervision
of an HCP, or by a provider of health care services (e.g., physical therapist) under orders of, or
on referral by, an HCP; or
B. At least one treatment by an HCP which results in a regimen of continuing treatment under the
supervision of the HCP.
3. Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Health Condition Requiring Treatments: A chronic condition which:
A. Requires periodic visits (at least twice a year) for treatment by an HCP, or by a nurse or
physician's assistant under direct supervision of an HCP;
B. Continues over an extended period of time; and
C. May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes,
epilepsy, etc.).
5. Permanent/Long Term Conditions Requiring Supervision: A period of incapacity which is
permanent or long term due to a condition for which treatment may not be effective, e.g. Alzheimer's,
a severe stroke. The patient must be under the continuing supervision of, but need not be receiving
active treatment by, an HCP.
6. Scheduled Multiple Treatments: Any period of absence to receive scheduled multiple treatments
(including any period of recovery) by an HCP or by a provider of health care services under orders
of, or on referral by, an HCP, either for restorative surgery after an accident or other injury, or for a
condition that would likely result in a period of incapacity of more than three consecutive calendar
days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation,
etc.), severe arthritis (physical therapy), kidney disease (dialysis).
Treatment: Includes examinations to determine if a serious health condition exists and evaluations of
the condition. Treatment does not include routine physical examinations, eye examinations, or dental
examinations.
Please fax the completed forms to the correct processing center.
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