Health Care Provider Certification - Metlife Form

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Employee Name: _________________________________________________ FMLA Claim #: _________________________________
Health Care Provider Certification - Family and Medical Leave
Note: Complete box “A” if you are submitting a leave request for your own serious health condition and you are not pursuing a claim for
disability benefits under your Employer’s disability plan. Complete boxes “A” and “B” of the form if you are submitting a leave request for
a family member who has a serious health condition.
A.
This Box Only To Be Completed By the Patient
(Patient may be the employee OR a family member of the employee)
Print Patient Name: ________________________________________________________________________________________
Medical Release: I authorize my Health Care Provider to release the information requested on this Certification to Metropolitan Life
Insurance Company (“MetLife”) and the employee’s employer and its affiliates for purposes of the evaluation of a family and medical leave
request (including federal Family and Medical Leave Act, and/or other categories), and to speak with a health care provider representing
the employer in order to clarify and authenticate the information on this Certification. I understand that this authorization allows my Health
Care Provider to disclose the underlying diagnosis of my serious health condition involved, if any. I understand that family and medical
leave may be delayed or denied if the information requested on the Certification is not provided, is unclear, or is incomplete. I understand
that I have the right to revoke this authorization in writing at any time by notifying MetLife in writing at MetLife Disability, P.O. Box 14590,
Lexington, Kentucky 40511-4590 and that if I do not, the authorization will remain in effect until the end of any FMLA leave granted by the
employer based on the health condition referenced on this Certification or the date on which the FMLA leave request is denied, whichever
is applicable. I understand that any revocation by me shall not apply to any person’s actions taken based on this authorization prior to
their receipt of my written revocation and that information disclosed pursuant to this authorization may be subject to redisclosure by the
recipient and no longer protected by privacy regulations of the U.S. Health and Human Services (65 CFR Parts 160 and 164.) A copy of this
authorization is as valid as the original.
Patient Signature: __________________________________________________________________________________________
Date: ____________________________________________________________________________________________________
mm/dd/yy
B.
This Box Only To Be Completed By the Employee
Care of Family Member (to be completed only by an employee needing family leave to care for a family member): State the care you will
provide and an estimate of the period during which care will be provided (start and end date), including a schedule if leave is to be taken
intermittently or if it will be necessary for you to work less than a full schedule:
Patient relationship: ________________________________________________________________________________________
Employee Signature: _______________________________________________________________________________________
Date: ____________________________________________________________________________________________________
mm/dd/yy
Remainder Of This Certificate To Be Completed by Health Care Provider
Here and elsewhere on this Certification the information sought relates only to the condition for which the employee is taking FMLA leave.
For purposes of this Certification, the following terms will have the meaning indicated: (a) “incapacity” and the forms of that word means inability
to work, attend school, or perform other regular daily activities due to the serious health condition, treatment therefor, or recovery therefrom;
(b) “treatment” and the forms of that word includes examinations to determine whether a serious health condition exists and evaluations
of the condition and does not include routine physical, eye, or dental examinations; (c) a “regimen of continuing treatment” includes,
for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health
condition, but does not include the taking of over-the-counter medications, bed rest, drinking fluids, exercise and other similar activities that can
be initiated without a visit to a health care provider.
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HCPC-FMLA 5979 (07/07) eF

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