Health Care Provider Certification - Family And Medical Leave

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HEALTH CARE PROVIDER CERTIFICATION
Family and Medical Leave
PD 615A
This form is used to provide certification per FMLA and OFLA regulations and law.
Section I: Employee Completes this Section
Employee’s Name: ____________________________________________________________________________
Patient’s Name: _______________________________________________________________________________
(Please check one) Relationship to patient:
self
spouse
parent
child (age _____)
domestic partner
parent-in-law
grandparent
grandchild
parent of domestic partner
child of a domestic partner (age ___)
Section II: Health Care Provider Completes this Section
Please complete all sections in order for the agency to determine Family and Medical leave entitlement.
Caution: Per the Genetic Information Nondiscrimination Act of 2008 (GINA) this agency is not requesting or requiring genetic
information* of its employees or their family members. In order for us to comply with this law, we ask that you not provide any genetic
information when responding to this request for medical information.
1. Please mark all that pertain to this patient (descriptions are on Page 2 of this certification):
A.
Requires hospital care (hospice, residential care facility)
B.
Requires absence from work plus treatment
C.
Pregnancy disability or requires prenatal care
D.
Chronic condition requiring treatment
E.
Permanent or long-term condition requiring supervision
F.
Requires multiple treatments for a non-chronic condition
G.
None of the above
Describe the medical facts that support your above certification. ___________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
2. Approximate date this condition began? _____________________________________________________________
3. Probable duration of the patient’s present incapacity? __________________________________________________
4. Is this for either a chronic condition or for pregnancy?
yes
no
If yes, is the patient presently incapacitated?
yes
no
___________________________________________
If yes, what is the expected duration of the incapacity?
__________________________________________________________
What is the expected frequency of the incapacity?
5. Will it be necessary for the employee to take time off intermittently or work on a reduced schedule due to the patient’s
condition or treatment?
yes
no
If yes, what is the expected frequency for the absence?
________
,
_______
_______
_______
days per week
days per month,
reduce hours worked in a day to
for
days per week,
) ________________________________________________________________________________
other (describe
6. Will the patient require a regimen of treatments?
yes
no
If yes, describe the nature of the treatments, number of
______________________________________________________
treatments needed and the intervals between treatments
_______________________________________________________________________________________________
7. If the patient is not the employee, will the patient need assistance for basic medical or personal needs, or safety or
n/a patient is the employee If no, would the employee’s presence to provide psychological
transportation?
yes
no
comfort be beneficial or assist in the patient’s recovery?
yes
no
____________________________________________
_________________________________________________
______________________
Signature of Health Care Provider
Printed Name of Health Care Provider
Date Signed
Field of practice: _______________________Health Care Provider address: _______________________________
Return this form to the patient or fax to the attention of:
Oregon Department of Fish & Wildlife-Human
Resources at Fax # 503/947-6050 (marked-CONFIDENTIAL)

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