Certification By Service Member'S Health Care Provider For Caregiver Military Family Leave

CERTIFICATION BY SERVICE MEMBER’S HEALTH CARE

PROVIDER FOR CAREGIVER MILITARY FAMILY LEAVE – FMLA

SECTION I: For completion by the EMPLOYEE and/or the COVERED SERVICE MEMBER for whom the

Employee is requesting leave (This section must be completed before any of the below sections can be completed

by a health care provider.)

Name of Employee Requesting Leave to Care for Covered Service member:

Name of Covered Service Member (for whom employee is requesting leave to care):

Relationship of Employee to Covered Service Member:

____ Spouse ____ Parent ____ Son ____ Daughter ____ Next of Kin

Is the Covered Service Member a Current Member of the Regular Armed Forces, the National Guard or

Reserves? ____ Yes ____ No

If yes, please provide the covered service member’s military branch, rank and unit currently assigned to:

___________________________________________________________________________________________

Is the covered service member assigned to a military medical treatment facility as an outpatient or to a unit

established for the purpose of providing command and control of members of the Armed Forces receiving

medical care as outpatients (such as a medical hold or warrior transition unit)? ____ Yes ____ No. If yes,

please provide the name of the medical treatment facility or unit: ___________________________________

Is the covered service member on the Temporary Disability Retired List (TDRL)? ____ Yes ____ No

Describe the care to be provided to the covered service member and an estimate of the leave needed to provide

the care: ________________________________________________________________________

_________________________________________________________________________________________

SECTION II: For completion by a United States Department of Defense (“DOD”) Health Care Provider or a Health

Care Provider who is either (1) a United States Department Of Veterans’ Affairs (“VA”) health care provider,

(2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE

authorized private health care provider. If you are unable to make certain of the military-related determinations

contained below in Part B, you are permitted to rely upon determinations from an authorized DOD representative

(such as a DOD recovery care coordinator). (Please ensure that Section I above has been completed before completing

this section.) Please be sure to sign the form on the last page.

Health Care Provider’s Name (Please print):

Health Care Provider’s Signature:

Date:

Address:

Phone number:

Fax number:

Specialty/Type of Practice:

Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD

TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized

health care provider: _________________________________________________________________________

revised 4/30/09

APWU FORM 4

Certification By Service Member'S Health Care Provider For Caregiver Military Family Leave - Fmla