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Form Fml 501 - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 2

For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the

FMLA to care for your patient. Answer, fully and completely, all applicable parts below. 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 patient needs care. The last page provides space for

additional information, should you need it. Please be sure to sign the form on the last page.

Provider’s name: _____________________________________________________________________________

Business Address: ___________________________________________________________________________

Type of practice / Medical specialty: _____________________________________________________________

Telephone:(________)____________________________

Fax:(_________)_______________________________

PART A: MEDICAL FACTS

1. Approximate date condition commenced: ________________________________________________________

Probable duration of condition: ________________________________________________________________

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: _____________________________________________________

Was medication, other than over-the-counter medication, prescribed? _____No _____Yes.

Will the patient need to have treatment visits at least twice per year due to the condition? ____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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Form Fml 501 - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 2