University Of Central Florida Certification Of Health Care Provider Form For A Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 2
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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 2 of 2
2. Is the medical condition pregnancy? Yes _____ No _____ If yes, expected delivery date:
3. Describe diagnosis and other relevant medical facts related to the condition for which your patient needs care (such
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
PART B: Amount of Care and Leave Needed (Please be specific on amount of time and/or dates. Keep in mind your patient’s need
for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety, transportation needs,
physical or psychological care.)
4. Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any time
for treatment and recovery? Yes _____ No _____
If yes, estimate the beginning and end dates for the period of incapacity:
During this time will the patient need care? Yes_____ No_______
Explain the care needed by the patient and why such care is medically necessary:
5.
Will the patient require follow-up treatments, including any time for recovery? Yes ____ No _____
_
If yes, are the treatments medically necessary? Yes _____ No _____
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment,
including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
6. Will the patient have flare-ups of their condition? Yes ____ No_____ If yes, how often?
If yes, how long will each episode last?
(please note if hours or days)
If yes, explain the care the patient will need during each flare-up, and why such care is medically necessary:
Based on your patient’s treatment plan, which of the following are you recommending for our employee to care for your patient:
Not work at all (patient requires full time care): _____Work intermittently: ______ Work a reduced work schedule:
If our employee could care for the patient on an intermittent or reduced work schedule basis during the patient’s recovery (e.g. one
day off per week for six months), please estimate the hours/days your patient needs care from our employee:
______________hour(s) per day; ______________ days per week from _______________ through _______________ (dates)
ADDITIONAL INFORMATION: Identify Question Number with Your Additional Answer, attach addition sheet if necessary:
Signature of Health Care Provider
Date
Revised Feb 2013
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