Health Care Provider Certification - Metlife Form Page 3
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4Employee Name: _________________________________________________ FMLA Claim #: _________________________________
Patient’s Name: _______________________________________________________________________________________________
8. Will the patient need future treatments (or a regimen of continuing treatment) for the serious health condition? Yes No
If yes, please describe the nature of the treatments/regimen of continuing treatment.
9. Will any of the treatments be provided by another provider of health services? Yes No
If yes, please describe the nature of the treatments.
10. If the patient is the employee, please check each of the below that apply and answer the questions below each item that you check:
a. It will be necessary for the patient to take leave from work for a single, continuous block of time due to incapacity or treatment.
Please provide the dates of such incapacity:
b. It will be necessary for the patient to take leave from work either (or both):
Intermittently (i.e., to be absent from work on an occasional, irregular basis) due to incapacity or for treatment, or
On a reduced schedule basis (i.e., to work on less than a normal schedule) due to incapacity or for treatment.
If either or both of the above applies, please answer:
When (or how often) will the treatments or episodes of incapacity occur (e.g., will need to take up to 1 day every 10 days [or 3 days/month]
over the next 6 months)? Provide actual or estimated dates of treatment or incapacity.
How many treatments or episodes of incapacity will there be?
When will all the foreseeable treatments and episodes of incapacity, including period for recovery, be over?
c. The employee is unable to perform any kind of work.
d. T he employee is unable to perform one or more of the essential functions of the employee’s position (based on information regarding
the position provided to you by the employee or the employer). If so, which functions is the employee unable to perform?
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HCPC-FMLA 5979 (07/07) eF
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