Certification of Health Care Provider for
Family Member’s Serious Health Condition
(Family and Medical Leave Act)
EMPLOYEE NAME: _______________________ EMPLOYEE ID: ________________________________
CASE NUMBER: __________________________ EMPLOYER NAME: ____________________________
For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete this section before giving this form to your family
member or his/her 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 to care for a covered family
member with a serious health condition. 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. 29 C.F.R. § 825.313. Your employer must give you at least 15
calendar days to return this form to your employer. 29 C.F.R. § 825.305.
Return a complete and sufficient medical certification to:
Sedgwick
P.O. Box 9830
Calabasas, CA 91372-0830
Fax: 818-591-7664
Name of family member for whom you will provide care:
________________________________________________________________________________________
First
Middle
Last
Relationship of family member to you:
Spouse
Father
Mother
Son
Daughter
Other: ____________________________
If family member is your father, mother, son or daughter, what is their date of birth:_________________________
Describe the care you will provide to your family member and estimate the amount of leave needed to provide
care:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________
_______________________________________
Employee Signature
Date
FML 501
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