Family And Medical Leave Act (Fmla) Medical Certification Form Page 6
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9Family 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)
d) Scheduled Multiple Treatments
Please answer ALL of the following questions:
First Day incapacitated for this current incident: ____/____/____
Last Day incapacitated for this current incident: ____/____/____
The patient will receive the following treatment:
Treatments will commence on ____/____/____ through ____/____/____.
The frequency of treatment is (#) ____ times per (circle one: week, month, year)
The approximate length of the appointment (including travel time) is __________ (circle one: minutes, hours,
days, weeks, months) (indicate range, if applicable)
The period required for recovery from treatment is (#) ____ (circle one: minutes, hours, days, weeks).
e) Pregnancy
The patient's pregnancy was confirmed on ___/___/____ with an estimated delivery date (EDC) of ___/___/____
The patient is scheduled for approximately (#) ____ prenatal appointments.
The approximate length of the prenatal appointment is (#) ____ (circle one: minutes, hours)
Do you presently anticipate a need for the patient to be absent from work during her pregnancy?
____ Yes ____ No
If yes, please describe the medical facts that support this need: _________________________
_______________________________________________________________________________
How often do you expect this patient to be incapacitated due to this medical 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)
4. If a Reduced Work Schedule is necessary upon an employee's return to duty, please provide a description of the
required work schedule.( i.e. number of hours per day) (#) ______ from ___/___/___ through ___/___/___.
SECTION C: (TO BE COMPLETED BY THE TREATING HCP IF THE LEAVE REQUEST IS TO CARE FOR A FAMILY
MEMBER. PLEASE NOTE: INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION AND MAY RESULT IN
DENIAL OF FMLA.)
Patient's Name ________________________ Relationship to Employee __________ Date of Birth ___/___/___
5. It is necessary for the employee to be absent from work from ___/___/___ through ___/___/___ to care for this family
member. (Please check any of the following and complete the applicable information.)
Full Time Leave - Taken in consecutive, full day increments
Follow-up appointment to Full Time Leave: ___________________________________________
Duration of the follow-up appointment, that employee needs to be away from work: (#) ____ (circle one: minutes, hours)
Intermittent Leave - Taken periodically over an extended period of time, with a likely frequency of (#)___ to
(#)____ times per (circle one: week, month, year ) with a probable duration of (#)____ (circle one: minutes, hours,
days, weeks) for a period of (#) ____ (circle one: weeks, months)
Reduced Work Schedule -Taken on consecutive days; the employee is able to work some of his/her work
schedule each day. The employee is able to work (#)____ hours per day.
Please fax the completed forms to the correct processing center.
Page 6 of 9
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