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Family And Medical Leave Certification Of Health Care Provider For Personal Serious Health Condition - University Of Washington Page 2

To Employee - Complete the following information on every page

University of Washington

(not for HMC or UWMC staff)

Family and Medical Leave

Employee Name:

Certification of Health Care Provider

Department:

for Personal Serious Health Condition

Employee Phone:

Human Resources

Employee Email:

Was your patient referred to other health care provider(s) for evaluation or treatment?

Yes

If yes, describe the nature and expected duration of the treatments:

Need for Leave or Work Schedule Adjustments

Will your patient be incapacitated for a single, continuous period of time including time for treatment and recovery?

Yes

If yes, estimate the beginning and ending dates for the period of incapacity: from (date) ______________ to (date) ______________

Will your patient be incapacitated in a manner that requires intermittent leaves of absence from work or a reduction in the amount of time worked per

week due to his/her medical condition, including any time for treatment and recovery?

Yes

If yes, please describe the nature of the intermittent leave or reduced work schedule that you believe is medically necessary:

This work schedule needs to be in place from (date) ______________ to (date) ______________

Will the condition(s) cause episodic flare-ups that prevent your patient from performing his/her job functions?

Yes

If so, please explain:

Based upon your 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: _____ of times per ______ week(s) -or- _____ month(s)

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

Are follow-up treatment appointments medically-necessary for your patient?

Yes

If yes, describe the anticipated treatment schedule and any treatment recovery period(s):

Health Care Provider Information (please complete or attach business card)

Name (please print) __________________________________________________ Specialty ____________________________________________

Business Address ____________________________________________________________________________ Phone ______________________

Health Care Provider Signature

_________________________________________________________________ Date _____________________________

April 30, 2015

Family And Medical Leave Certification Of Health Care Provider For Personal Serious Health Condition - University Of Washington Page 2

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