Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition (Page 2 of 4) in pdf

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

PART A: MEDICAL FACTS

1. Approximate date condition commenced: __________________________________________________

Probable duration of condition: __________________________________________________________

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?

___No ___Yes If so, dates of admission: __________________________________________________

Date(s) you treated the patient for condition:________________________________________________

Was medication, other than over-the-counter medication, prescribed? ___No ___Yes

Will the patient need to have treatment visits at least twice per year due to the condition? ___No ___Yes

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical

therapist)?____ No ____Yes If so, state the nature of such treatments and expected duration of treatment:

___________________________________________________________________________________

2. Is the medical condition pregnancy? ___No ___Yes If so, expected delivery date: _________________

3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such

medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of

specialized equipment):

___________________________________________________________________________________

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s

need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional,

safety or transportation needs, or the provision of physical or psychological care:

4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and

recovery? ___No ___Yes

Estimate the beginning and ending dates for the period of incapacity: _____________________________

During this time, will the patient need care? ___ No ___ Yes

Explain the care needed by the patient and why such care is medically necessary:

____________________________________________________________________________________

Business Service Center HR-BEN-070

Page 2 of 4

Rev. 11.15.12

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