University Of Central Florida Certification Of Health Care Provider Form For A Family Member'S Serious Health Condition (Family And Medical Leave Act)
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2University of Central Florida Certification of Health Care Provider Form for a Family Member’s Serious Health Condition
(Family and Medical Leave Act)
Page 1 of 2
University of Central Florida, Human Resources, 3280 Progress Drive, Suite 100, Orlando, FL 32826
Phone: 407-823-2771; Fax: 407-823-1095
Informational Instructions to Supervisor/Dean/Director: The Family and Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA protections because of a need for leave to care for a covered family member with a serious
health condition to submit a medical certification issued by the health care provider of the covered family member. You may not ask
the employee to provide more information than allowed under the FMLA regulations. The University must generally maintain records
and documents relating to medical certifications, recertifications, or medical histories of employees’ family members, created for
FMLA purposes as confidential medical records in separate files/records from the usual personnel files, with an FMLA Administrator.
SECTION I: For Completion by the Employee. Instructions: Please complete Section I before giving this form to your family
member or his/her medical provider. The FMLA permits the University to require that you submit a timely, complete, and sufficient
medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. Your
response is required to obtain or retain the benefit of FMLA protections. Failure to provide a complete and sufficient medical
certification may result in a denial of your FMLA request. The University must give you at least 15 calendar days to return this form.
Your name:
Last
First
Middle
Name of family member for whom you will provide care:
Relationship of family member to you:
If family member is your son or daughter, date of birth:
Describe care you will provide to family member and estimate leave needed to provide care:
Employee ID
Employee Signature
Date
SECTION II: For Completion by the Health Care Provider. Instructions: The employee listed above has requested medical
leave under FMLA to care for your patient. Answer, fully and completely, all applicable parts. Your answer should be your best
estimate based on 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 employee is seeking leave and the care they need to provide to your patient. Please be sure to sign the form on the last
page.
Provider’s name and business address:
Type of practice / Medical specialty:
License Number Issued by the State of Florida:
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? Yes _____ No ________
If so, dates of admission:
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition? Yes _____ No _____
Was medication, other than over-the-counter medication, prescribed? Yes ______ No______
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? Yes _____ No _____
If so, state the nature of such treatments and expected duration of treatment:
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