Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act)
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1
2Certification of Health Care Provider for
Employee’s Serious Health Condition
(Family and Medical Leave Act)
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee
seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the
employee’s health care provider.
Employer name and contact: ________________________________________________________________________________________
Employee’s job title: ____________________________________________ Regular work schedule: ______________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your
own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections.
Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. It is your responsibility to
ensure that the health care provider returns the completed form to you or Employee Health 205.996.9274 within 15 calendar days of
receipt.
Your name: ______________________________________________________________________________________________________
First
Middle
Last
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all
applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be
your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such
as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for
which the employee is seeking leave. Do not provide information about genetic tests, genetic services, or the manifestation of disease or
disorder in the employee’s family members. Please be sure to sign the form on the last page.
Provider’s name and business address: ________________________________________________________________________________
Type of practice / Medical specialty: ___________________________________________________________________________________
Telephone: (________)_______________________________________
Fax:(_________)___________________________________
PART A: MEDICAL FACTS
1.
Approximate date condition commenced: ___________________________________________________________________________
Probable duration of condition: ___________________________________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? ______ No _____ Yes
If so, dates of admission: ___________________________________
Date(s) you treated the patient for condition: ________________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition? _____No _____Yes
Was medication, other than over-the-counter medication, prescribed? _____No _____Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? _____ No _____ Yes
If so, state the nature of such treatments and expected duration of treatment:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Revised 02/2016
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