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Certification By Health Care Provider Of Employee'S Serious Health Condition Form - Los Angeles Unified School District Page 3

Is it medically necessary for the employee to be absent from work during the flare-ups? ___ No ____ Yes. If yes, explain:

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

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

__________________________________________

______________________________________

Signature of Health Care Provider

Date

Verification from Health Care Provider

Provide the following information pertaining to your profession:

a) Your Name_______________________________________________________________________

b) Your Name as Health Care Provider ___________________________________ Degree __________

c) Specialty/Type of Practice__________________________________________ License #__________

d) Type of License_______________________________ Telephone # (____)___________________

e) Address_________________________________________________________Zip _____________

Certify to the following: “I certify that I am the treating health care provider for the above-named patient who is under my

professional care. All of this information is true and correct to the best of my knowledge.”

Original Signature (no stamp): ______________________________ Date: ______________

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07/2012

Certification By Health Care Provider Of Employee'S Serious Health Condition Form - Los Angeles Unified School District Page 3