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SECTION III – To be completed by HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA

and/or CFRA to care for your patient. Please 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 “indefinite,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA/CFRA coverage.

THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA): The Genetic Information

Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or

requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.

To comply with this law, we are asking that you not provide any genetic information when responding to this request for

medical information. ‘Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results

of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or

received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or

an embryo lawfully held by an individual or family member receiving assistive reproductive services.

NOTE: DO NOT DISCLOSE ANY UNDERLYING DIAGNOSES WITHOUT THE PATIENT’S CONSENT.

Limit your responses to the condition for which the patient needs the employee’s care. Please be sure to sign and

date the form on Page 2.

Provider's Name:

Business Address:

Telephone

Fax

PART A: MEDICAL FACTS

(1) Approximate date condition commenced:

Probable duration of condition:

__________________

From: _______________ To: ________________

(2) Page 3 describes what is meant by a “serious health condition” under both the FMLA and CFRA. Does the

Yes

patient’s condition qualify under any of the categories described?

If yes, which type of serious health condition listed on Page 3 applies:

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:

(1) Will the patient be incapacitated for a single continuous period of time, including any time for treatment and

Yes

recovery?

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

During this time, does the patient’s condition warrant the participation of the employee? (In answering this

Yes

question, please review the employee’s statement of care in Section II, page 1.)

If the employee has requested leave on an intermittent or reduced schedule leave basis (see

Yes

(2)

answer in Section II, page 1, question 2), is it medically necessary for the patient to receive care on

an intermittent or reduced schedule basis, including any time for recovery?

If yes, estimate the hours the patient needs care from the employee:

Hours per Day __________

Days Per Week: __________

From: _______________

Through: _______________

SIGNATURE

Signature of HEALTH CARE PROVIDER

Date

2 of 3

Print Form

Certification Of Health Care Provider For Family Member'S Serious Health Condition - Family And Medical Leave Act ("Fmla") & California Family Rights Act ("Cfra") Page 2

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