Uab Certification Of Health Care Provider For Family Member'S Serious Health Condition
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1
2Certification of Health Care Provider for
Family Member’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 to care for a covered family member with a serious health condition to submit a
medical certification issued by the health care provider of the covered family member.
Employer name and contact: _____________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family member or his/her 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 to care for a covered family member with a 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 via fax# 205 996-9274 within 15 calendar days of receipt.
Your name: ___________________________________________________________________________________________________
First
Middle
Last
Name of family member for whom you will provide care: ________________________________________________________________
First
Middle
Last
Relationship of family member to you: ______________________________________________________________________________
If family member is your son or daughter, date of birth: _____________________________________________________________
Describe care you will provide to your family member and estimate leave needed to provide care:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________
____________________________
Employee Signature
Date
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your
patient. Answer, fully and completely, all applicable parts below. 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 patient needs leave. Do not provide information about genetic tests or
genetic services. Page 2 provides space for additional information, should you need it. Please be sure to sign the form on the last page.
Provider’s name and business address: ____________________________________________________________________________
(Please Print)
Type of practice / Medical specialty: _______________________________________________________________________________
Telephone: (________)____________________________
Fax:(_________)________________________
PART A: MEDICAL FACTS
1.
Approximate date condition commenced: _______________________________________________________________________
Probable duration of condition: ________________________________________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
______No _____Yes If so, dates of admission: _________________________________________________________________
Revised 02/2016
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