Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition (Page 3 of 4) in pdf

Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition Page 3

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time

required for each appointment, including any recovery period:

___________________________________________________________________________________

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

___________________________________________________________________________________

6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?

___No ___Yes

Estimate the hours the patient needs care on an intermittent basis, if any:

_______ hour(s) per day; _______ days per week from ________________ through ________________

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

____________________________________________________________________________________

7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal

daily activities? ____No ____Yes

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the

frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6

months (e.g., 1 episode every 3 months lasting 1-2 days):

Frequency: _____ times per _____ week(s) _____ month(s)

Duration: _____ hours or ____ day(s) per episode

Does the patient need care during these flare-ups? ____ No ____ Yes

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

____________________________________________________________________________________

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

___________________________________________________________________________________

Section IV – Signature of Health Care Provider

I do hereby certify that to the best of my knowledge the above information is true and correct.

Signature

Date

Business Service Center HR-BEN-070

Page 3 of 4

Rev. 11.15.12

Mta Fmla Certification Of Health Care Provider Family Member'S Serious Health Condition Page 3