Family And Medical Leave Act (Fmla) Medical Certification Form Page 4
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9Family and Medical Leave Act (FMLA) Certification Form
Verizon 12/2011
Employee's Name: _________________________First Day of Absence _____________ EMPLID __________
INSTRUCTIONS: We estimate that it will take an average of ten (10) minutes to complete this form.
Please note: Incomplete Form Will Be Returned For Completion
1. Employee Complete Section A
2. Employee's Treating Health Care Provider - Complete Sections B and D
3. Family Member's Treating Health Care Provider - Complete Sections B, C, and D
SECTION A: (TO BE COMPLETED BY THE EMPLOYEE. PLEASE BE ADVISED THAT KNOWINGLY PROVIDING FALSE
OR INACCURATE INFORMATION IN THIS CERTIFICATION IS A VIOLATION OF THE COMPANY'S CODE OF BUSINESS
CONDUCT.)
Type of Leave: (check all that apply)
New Request
Extension/Recertification
On the Job Injury
Reason for Leave: (check one)
A serious health condition that makes you unable to perform any one of the essential functions of your job.
A serious health condition affecting your spouse, child or parent for which you are needed to provide care.
The birth of your child, or the placement of a child with you for adoption or foster care for the period beginning
___/___/____ through ___/___/___. You must attach documentation supporting the date of your child's birth, or the
date of foster placement or adoption.
Requested FMLA: (check all that apply)
Full Time Leave - Taken in consecutive, full day increments.
Intermittent Leave - Taken periodically over an extended period of time.
Reduced Work Schedule - Taken on consecutive days; employee is able to work some of his/her work schedule
each day.
SECTION B: (TO BE COMPLETED BY THE TREATING HCP. PLEASE NOTE: INCOMPLETE FORMS WILL BE
RETURNED FOR COMPLETION AND MAY RESULT IN DENIAL OF FMLA.)
1A. Describe the medical facts, which support your certification, including a brief statement as to how the medical facts meet
the criteria for a serious health condition under the FMLA (see page one). The medical facts must be sufficient to support
the need for leave. Such medical facts may include information on symptoms, diagnosis, hospitalization, doctor visits,
whether medication has been prescribed, any referrals for evaluation or treatment or any other regimen of continuing
treatment.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
1B. If leave is for the employee's own health condition, please provide information sufficient to establish that the employee
cannot perform the essential function(s) of the employee’s job as well as the nature of any other work restrictions, and
the likely duration of such inability.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
2. This patient has been under my care for this health condition since: _____/_____/_____.
3. Does the patient's condition qualify as a serious health condition under the Family and Medical Leave Act (FMLA)? (See
page one for Family and Medical Leave Act Definitions for Health Care Providers.)
NO, the patient's condition does not qualify as a serious health condition under FMLA. (If you check this box, go directly to
Section D.)
YES, the patient's condition qualifies as a serious health condition according to the following category as described
by FMLA regulations. (Please check all that apply, and complete the applicable information.)
Please fax the completed forms to the correct processing center.
Page 4 of 9
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