Nc State University Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act)
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4Certification of Health Care Provider for
Employee's Serious Health Condition
(Family and Medical Leave Act)
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER:
The Family and Medical Leave Act (FMLA) provides that an employer may require an
employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued
by the the employee's health care provider. Please complete Section I before giving this form to your employee. Your response is
voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under
the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical
certifications, recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate
files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies,
and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Employer name: NC State University, Human Resources - Leave Team, Fax (888) 317-2890
Employee's job title:
Regular work schedule:
Employee's essential job functions:
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE:
Please complete Section II before giving this form to your 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 due
to your own 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. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name:
First
Middle
Last
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER :
Your patient has requested leave under the FMLA. Answer, fully and
completely all applicable parts. 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 employee is seeking leave. Do not provide information about genetic tests, as defined in 29
C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee's family
members, 29 C.F.R. § 1635.3(b). Please be sure to sign the form on the last page.
Provider's name and business address :
Type of practice / Medical specialty :
Telephone: (
)
Fax: (
)
CONTINUED ON NEXT PAGE
Questions about this form? Contact Leave Administration at (919) 515-2151
Page 1 of 4
Revised: May 2015
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