Form Fml 501 - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act)

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Certification of Health Care Provider for
Employee’s Serious Health Condition
(Family and Medical Leave Act)
EMPLOYEE NAME: ____________________________
EMPLOYEE ID: ______________________________
CASE NUMBER: _______________________________
EMPLOYER NAME: __________________________
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. Please be sure to sign the form on the last page.
Provider’s name and business address: ________________________________________
Type of practice / Medical specialty: _________________________________________
Telephone: (________) _______________________ Fax: (______)_________________
PART A: MEDICAL FACTS
1. Approximate date condition commenced: _______________________________________________________
Probably duration of condition: _______________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
_____ No _____ Yes. If so, dates of admission:
_________________________________________________________________________________________
Date(s) you treated the patient for condition:
_________________________________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition? _____ No _____ Yes.
Was medication, other than over-the-counter medication, prescribed? _____ No _____ Yes.
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g. physical therapist)?
_____No _____Yes. If so, state the nature of such treatments and expected duration of treatment:
_________________________________________________________________________________________
2. Is the medical condition pregnancy? _____ No _____ Yes. If so, expected delivery date: _________________
FML 501
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