Uab Certification Of Health Care Provider For Family Member'S Serious Health Condition Page 2
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1
2Date(s) you treated the patient for condition: _____________________________________________________________________
Was medication, other than over-the-counter medication, prescribed?
______No ______Yes
Will the patient need to have treatment visits at least twice per year due to the condition?
______No _____Yes
2.
Is the medical condition pregnancy? ______ No ______ Yes
If so, expected delivery date: ___________________
3.
Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may
include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PART B: AMOUNT OF CARE NEEDED
When answering these questions, keep in mind that your patient’s need for care by the
:
employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision
of physical or psychological care:
4.
Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery?
______No ______Yes Estimate the beginning and ending dates for the period of incapacity: __________________________
During this time, will the patient need care? ______No ______Yes.
Explain the care needed by the patient and why such care is medically necessary:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5.
Will the patient require follow-up treatments, including any time for recovery? ______No _____Yes
Estimate treatment schedule, if any, including the dates of any scheduled appointments, the time required for each appointment,
the care needed by the patient, and why such care is medically necessary including any recovery period:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6.
Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? ______No ______Yes.
Estimate the hours the patient needs care on an intermittent basis, if any: ______hour(s) per day; ______days per week from
___________through ___________ Explain the care needed by the patient, and why such care is medically necessary:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
7.
Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities?
______No ______Yes.
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the
duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency: ______times per ______week(s) ______month(s)
Duration: ______hours or ______day(s) per episode
Does the patient need care during these flare-ups? ______No ______Yes
Explain the care needed by the patient, and why such care is medically necessary: _____________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________
_____________________________
Signature of Health Care Provider
Date
Revised 02/2016
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