Form Fml 501 - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 4

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Explain the care needed by the patient, and why such care is medically necessary:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal
daily activities? _____No _____Yes
Based upon the 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: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours or ___ day(s) per episode
Does the patient need care during these flare-ups? _____No _____Yes.
Explain the care needed by the patient, and why such care is medically necessary:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________________________________________
*Important: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking you and your health care provider not to provide any
genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA includes
an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or
an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or
an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive
services.
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________ ___________________________________________
Signature of Health Care Provider
Date
FML 501
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