Family And Medical Leave Act (Fmla) Medical Certification Form Page 7
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9Family and Medical Leave Act (FMLA) Certification Form
Verizon 12/2012
Employee's Name: _________________________First Day of Absence _____________ EMPLID __________
SECTION C - continued: (TO BE COMPLETED BY THE TREATING HCP. PLEASE NOTE: INCOMPLETE FORMS
WILL BE RETURNED FOR COMPLETION AND MAY RESULT IN DENIAL OF FMLA.)
6. Does the patient require assistance for:
Basic Medical or Personal Needs
Yes
No
Transportation
Yes
No
Psychological Comfort
Yes
No
Safety
Yes
No
7. If leave is required to care for a child age 18 or older, the child must be incapable of self-care. The individual must
require active assistance or supervision to provide daily self-care in three or more of the activities of daily living (ADLs) or
instrumental activities of daily living (IADLs). If the employee has requested FMLA leave to care for a child age 18 or
older, please provide at least three ADLs/IADLs that the patient requires active assistance or supervision with.
(See page
one for the definition of ADLs and IADLs.)
SECTION D: (TO BE COMPLETED BY THE TREATING HEALTH CARE PROVIDER)
We strongly recommend that you retain a copy of this form in the event clarification of its content is needed. Incomplete
forms will be returned to the employee to be completed. This may result in a delay or denial of the employee's FMLA
approval.
I certify that the above information is true and correct:
Treating Health Care Provider's Printed Name
Signature
Date
Type of Practice
Address
Phone#
Fax#
Please fax the completed forms to the correct processing center.
Page 7 of 9
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