Health Care Provider Certification - Metlife Form Page 4
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4Employee Name: _________________________________________________ FMLA Claim #: _________________________________
Patient’s Name: _______________________________________________________________________________________________
11 If the patient is NOT the employee please check each that apply and answer the questions below each item that you check
a. T he patient’s incapacity, need for treatment, and/or need for care from the employee will take place in a single, continuous block
of time.
Please provide the dates of such incapacity:
b. The patient’s incapacity, treatments, or need for care from the employee:
will occur intermittently (i.e., on an occasional, irregular basis); or
will require the employee to work a reduced schedule (i.e., to work on less than a normal schedule).
If either or both of the above applies, please answer:
When (or how often) will the treatments, episodes of incapacity, and/or episodes of need for the employee’s care occur (e.g., will need
to take up to 1 day every 10 days [or 3 days/month] over the next 6 months)?
How many treatments or episodes of incapacity, and/or episodes of need for the employee’s care will there be?
When will all the foreseeable treatments, episodes of incapacity, and/or episodes of need for the employee’s care, including period for
recovery, be over?
c. The patient requires assistance for basic medical or personal needs or safety, or for transportation.
d. The employee’s presence to provide psychological comfort would be beneficial to the patient or assist in the patient’s recovery.
_______________________________________________________
_______________________________________________
mm/dd/yy
Health Care Provider Signature
Date
_______________________________________________________
_______________________________________________
Print Health Care Provider Name
Type of Practice
___________________________________________________________________________________________________________
Address
_______________________________________________________
_______________________________________________
Phone
Fax
Please return to the employer’s FMLA administrator at:
MetLife Disability
P.O. Box 14590
Lexington, Kentucky 40511-4590
Fax: 1-800-230-9531
Page 4 of 4
HCPC-FMLA 5979 (07/07) eF
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