Nalc Form 4 - Family And Medical Leave Act Form - Certification For Serious Injury Or Illness Of Current Covered Servicemember For Military Caregiver Leave Page 2
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2NALC Form 4 Family and Medical Leave Act Form
Employee: Return the completed form to the appropriate FMLA administration HRSSC address or fax (see attached sheet) and keep a copy for your own records.
Certification for Serious Injury or Illness of Current Covered Servicemember for Military Caregiver Leave
Section 2: For completion by 1) a United States Department of Defense (“DOD”) health care provider or health care provider
who is either: 2) a United States Department of Veterans Affairs (“VA”) health care provider, 3) a DOD TRICARE network author-
ized private health care provider, 4) a DOD non-network TRICARE authorized private health care provider, or 5) a health care
provider under the FMLA (as defined in 29 CFR 825.125). Please be sure to sign the form in the place provided at the end.
A. Health care provider information
Health care provider’s name (please print): _________________________________________________________
Health care provider’s business address: ___________________________________________________________
Telephone: (____) _____________ Fax: ___________________ Email: __________________________________
Type of practice/medical specialty: ________________________________________________________________
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Please indicate whether you are:
1. a DOD health care provider
2. a VA health care provider
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3. a DOD TRICARE network authorized provider
4. a DOD non-network TRICARE authorized healthcare provider
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5. a health care provider under the FMLA
B. Medical status
If you are unable to make certain of the military-related determinations contained in Part B below, you are permitted to rely upon
determinations from an authorized DOD representative (such as a DOD recovery care coordinator) or an authorized VA representative.
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1) Was the covered servicemember’s injury or illness incurred or aggravated in the line of duty on active duty?
Yes
No
2) Approximate date the serious injury or illness commenced or was aggravated: ___________________________
3) Probable duration of the serious injury or illness and/or need of care: __________________________________
4) Briefly state the medical facts regarding the covered servicemember’s health condition for which FMLA leave is requested:
____________________________________________________________________________________________
____________________________________________________________________________________________
5) Does the injury or illness render the covered service member medically unfit to perform the duties of his or her office, grade,
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rank or rating?
Yes
No
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6) Is the covered servicemember undergoing medical treatment, recuperation, or therapy?
Yes
No. If yes, please
describe medical treatment, recuperation or therapy:
____________________________________________________________________________________________
____________________________________________________________________________________________
C. Covered servicemember’s need for care by family member
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1) Does the patient require assistance for basic medical, hygiene, nutritional needs, safety, transportation?
Yes
No
2) If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in the patient’s
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recovery?
Yes
No
3) Will the covered servicemember need care for a single continuous period of time, including any time for treatment and
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recovery?
Yes
No
If yes, estimate the beginning and ending dates for this period of time: _________________________
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4) Will the covered servicemember require periodic follow-up treatment appointments?
Yes
No.
If yes, estimate the treatment schedule: _______________________________________
5) Is there a medical necessity for the covered servicemember to have periodic care for these follow-up treatment appointments?
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Yes
No
6) Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled follow-up
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treatment appointments (e.g., episodic flare-ups of medical condition)?
Yes
No. If yes, please estimate the frequency
and duration of the periodic care (e.g.: 2 times per week for 8 months lasting 1 day):
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hour(s) or _____ day(s) per event.
Signature of health care provider: ____________________________________________ Date: __________________________
NALC Form 4 (page 2 of 2) - 5/24/2013
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