Health Care Provider Certification - Metlife Form Page 2
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4Employee Name: _________________________________________________ FMLA Claim #: _________________________________
1. Patient’s Name: _____________________________________________________________________________________________
2. A “Serious Health Condition” means an illness, injury, impairment, or physical or mental condition that involves one of the following. If the
patient’s condition qualifies under any of the categories described, please check the applicable category:
Hospital Care. Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period
of incapacity or subsequent treatment in connection with, or consequent to, such inpatient care.
Absence Plus Treatment. A period of incapacity exceeding three (3) consecutive calendar days (including any subsequent treatment
or period of incapacity) also involving either: (a) treatment two or more times by a health care provider (or by a nurse or physician’s
assistant under direct supervision of a health care provider or by a provider of health care services such as a physical therapist under
orders of or on referral by a health care provider); or (b) treatment by a health care provider on at least one occasion which results
in a regimen of continuing treatment under the supervision of the health care provider.
Pregnancy. Any period of incapacity due to pregnancy or for prenatal care.
Chronic Condition Requiring Treatment. A chronic condition which requires periodic visits for treatment by a health care provider
(or by a nurse or physician’s assistant under the direct supervision of a health care provider), continues over an extended period of time
(including recurring episodes of a single underlying condition) and may cause episodic rather than a continuing period of incapacity.
Permanent/Long Term Condition Needing Supervision. A period of incapacity which is permanent or long-term due to a condition for
which treatment may not be effective. The patient must be under the continuing supervision of, but need not be receiving active treatment
by, a health care provider. Examples include Alzheimer’s, a severe stroke, or terminal stages of a disease.
Multiple Treatments (Non-Chronic Conditions). Any period of absence to receive multiple treatments (including any period of recovery
therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either
for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than
three (3) consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.),
severe arthritis (physical therapy), kidney disease (dialysis).
None of the Above. Please skip all remaining questions, sign the Certification and return it.
3. Describe the medical facts supporting your certification, including a brief statement as to how the medical facts meet the criteria of one
of these categories.
4. When did the serious health condition commence (if it has not yet begun, when will it begin)?
5. Is the patient incapacitated at the present time? Yes No
6. If the patient is not presently incapacitated, when and for how long will the patient be incapacitated?
7. When will the patient’s incapacity due to the serious health condition end?
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HCPC-FMLA 5979 (07/07) eF
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