Medical Certification For Family Members Form - County Of Sonoma
Download a blank fillable Medical Certification For Family Members Form - County Of Sonoma in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Certification For Family Members Form - County Of Sonoma with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4COUNTY OF SONOMA, COUNTY AGENCIES AND SPECIAL DISTRICTS
MEDICAL CERTIFICATION FOR FAMILY MEMBERS
Please use this form for a Leave of Absence requiring medical certification for an employee to care for a covered family
member with a serious health condition. This form meets requirements of the California Family Rights Act (CFRA) and the
federal Family Medical Leave Act (FMLA).
Instructions: The employee should complete Section I, then provide this form to the family member or his/her health care
provider. Your assistance in providing a complete medical certification will help expedite approval of your leave request.
Without complete and sufficient medical certification, your request may be delayed or even denied. Please return the
completed form within 15 calendar days, unless it is not practicable to do so despite your diligent good faith efforts.
Section I – FAMILY MEMBER
Employee's Name:__________________________________________________
Department:___________________________________
First
Middle
Last
I, ___________________________, hereby authorize ______________________ (physician/practitioner), to provide the information
contained in the Sonoma County Medical Certification form below. This certification will be provided to Sonoma County
(family member’s employer) for the purpose of determining ________________________ (employee) eligibility for
family/medical leave, as provided by state and federal law.
I,___________________________ (patient), understand that I have a right to receive a copy of this authorization.
_____________________________________________
________/________/_______
Signature of Patient
Date
Section II – HEALTH CARE PROVIDER
NOTE: THE HEALTH CARE PROVIDER IS NOT TO DISCLOSE THE UNDERLYING DIAGNOSIS WITHOUT THE CONSENT OF THE PATIENT.
1.
Employee's Name:______________________________________________________________________________
2.
Patient’s Name: ________________________________________________________________________________
3.
Relationship to employee: ______________________________________________________________________
4.
Date medical condition or need for treatment began:
_________/_________/_________
5.
Probable duration of serious health condition or need for treatment: ______________________________
6.
Type of leave requested:
Continuous
Intermittent
When family care leave is needed to care for a seriously-ill family member, the employee shall state the care he or she will
provide and an estimate of the time period during which this care will be provided, including a schedule if leave is to be
taken intermittently or on a reduced work schedule. This information shall be provided separately and confidentially to the
health care provider for use in completing the below information.
7.
The definitions below describe what is meant by a "serious health condition" under both the federal Family and
Medical Leave Act (FMLA) and the California Family Rights Act (CFRA). Please check the box next to the
appropriate category for the patient’s condition.
A "serious health condition" means an illness, injury, impairment, or physical or mental condition that involves one
of the following:
A. Hospital Care
Page 1
Appendix C
ADVERTISEMENT
0 votes
Related Articles
Related forms
Public Pool Permit Application Form - County Of Sonoma Department Of Health Services Environmental Health & Safety
Legal
Donor's Vacation Transfer Form For Employees With A Catastrophically Ill Family Member Form - Office Of The Controller
Business
Certification Of Health Care Provider For Family Member's Serious Health Condition - Family And Medical Leave Act ("fmla") & California Family Rights Act ("cfra")
Business
Related Categories
Parent category: Business