Family And Medical Leave Act (Fmla) Medical Certification Form Page 5

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Family and Medical Leave Act (FMLA) Certification Form
Verizon 12/2012
Employee's Name: _________________________First Day of Absence _____________ EMPLID __________
SECTION B - continued: (TO BE COMPLETED BY THE TREATING HCP. PLEASE NOTE: INCOMPLETE
FORMS WILL BE RETURNED FOR COMPLETION AND MAY RESULT IN DENIAL OF FMLA.)
Question 3 (cont'd)
a) Hospital Care (Inpatient – overnight stay)
Please answer ALL of the following questions:
 First Day incapacitated for this current episode: ____/____/____
Last Day incapacitated for this current episode: ____/____/____
 Admit Date: ____/____/____ Discharge Date: ____/____/____
 Follow-up Appointment Date(s): ______________________________________
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If employee needs to be absent from work for follow-up appointment(s), please indicate the duration of the
follow-up appointment(s): (#)_______(circle one: minutes, hours)
b) Absence Plus Treatment (Acute)
Please answer ALL of the following questions:
 First Day incapacitated for this current episode: ____/____/____
Last Day incapacitated for this current episode: ____/____/____
The patient's period of incapacity exceeded three (3) consecutive calendar days and involved treatment two (2) or
more times, within 30 days of the first day of incapacity, absent extenuating circumstances, by the health care
provider, or treatment on at least one occasion which resulted in a regimen of continuing treatment. If a regimen of
continuing treatment is required under your supervision, provide a general description of the regimen (e.g.,
prescribed medication, physical therapy):
 Follow-up appointment date(s): ___________________________________________
 If employee needs to be absent from work for follow-up appointment(s), please indicate the duration of the follow-up
appointment(s): (#)_______ (circle one: minutes, hours)
c)  Chronic Condition Requiring Treatment/ Permanent Long Term Condition Requiring Supervision
The patient requires periodic visits, at least twice a year, to the health care provider for treatment, the condition
continues over an extended period of time, and the condition may cause episodic rather than a continuing
period of incapacity. The patient requires the following treatment including prescribed medication,
examinations and/or evaluations of the condition:
Please complete ALL of the following questions that apply:
 Current Absence
 Period of incapacity for this absence : From ____/____/____ Through ____/____/____
Future Intermittent Absences (Please complete the following information.)
 How often do you expect this patient to be incapacitated due to their health condition? (indicate range, if applicable)
(#)______ times per (circle one: week, month, year) each lasting (indicate range, if applicable) (#)______ (circle
one: minutes, hours, days, weeks) for a period of (#)______(circle one: weeks, months)
Please fax the completed forms to the correct processing center.
Page 5 of 9

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