Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition printable pdf download

Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

Section I – Instructions for the Employee

NOTE: Remember to complete and submit an HR-BEN-028: Family and Medical Leave Act Application Form to your Agency HR or FMLA

Coordinator.

Please complete Section I before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that

you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a

serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§

2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313.

Your employer must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.

If you have any questions, please contact MTA Business Service Center (BSC) at 646-376-0123 or .

Section II – Employee Information

Print Name

Last

First

Suffix

BSC ID:

BSC

B&T

Police

MaBSTOA

Department:

Employer

(check one)

SIR

LIRR

MNR

MTA Bus

NYCTA

Job Title:

Regular Work Schedule

Street Address

City

State

Zip Code

Phone (H)

Phone (W)

Name of Family Member for whom you will provide care:

Relationship of family member to you:

Parent

Spouse

Child

If son or daughter, date of birth:

Describe the care you will provide to your family member and estimate leave needed to provide care:

Employee Signature

Date

Section III – For Completion by the HEALTH CARE PROVIDER

The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable parts below.

Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based

upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or

“indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Page 3

provides space for additional information, should you need it. Please be sure to sign the form on page 3.

Provider’s Name:

License number:

State:

Type of Practice/ Medical Specialty:

Provider’s Address:

City:

State:

Zip Code:

Telephone:

Fax:

Business Service Center HR-BEN-070

Page 1 of 4

Rev. 11.15.12

Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition

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