Certification By Service Member'S Health Care Provider For Caregiver Military Family Leave - Fmla
Download a blank fillable Certification By Service Member'S Health Care Provider For Caregiver Military Family Leave - Fmla in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Certification By Service Member'S Health Care Provider For Caregiver Military Family Leave - Fmla with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2CERTIFICATION BY SERVICE MEMBER’S HEALTH CARE
PROVIDER FOR CAREGIVER MILITARY FAMILY LEAVE – FMLA
SECTION I: For completion by the EMPLOYEE and/or the COVERED SERVICE MEMBER for whom the
Employee is requesting leave (This section must be completed before any of the below sections can be completed
by a health care provider.)
Name of Employee Requesting Leave to Care for Covered Service member:
Name of Covered Service Member (for whom employee is requesting leave to care):
Relationship of Employee to Covered Service Member:
____ Spouse ____ Parent ____ Son ____ Daughter ____ Next of Kin
Is the Covered Service Member a Current Member of the Regular Armed Forces, the National Guard or
Reserves? ____ Yes ____ No
If yes, please provide the covered service member’s military branch, rank and unit currently assigned to:
___________________________________________________________________________________________
Is the covered service member assigned to a military medical treatment facility as an outpatient or to a unit
established for the purpose of providing command and control of members of the Armed Forces receiving
medical care as outpatients (such as a medical hold or warrior transition unit)? ____ Yes ____ No. If yes,
please provide the name of the medical treatment facility or unit: ___________________________________
Is the covered service member on the Temporary Disability Retired List (TDRL)? ____ Yes ____ No
Describe the care to be provided to the covered service member and an estimate of the leave needed to provide
the care: ________________________________________________________________________
_________________________________________________________________________________________
SECTION II: For completion by a United States Department of Defense (“DOD”) Health Care Provider or a Health
Care Provider who is either (1) a United States Department Of Veterans’ Affairs (“VA”) health care provider,
(2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE
authorized private health care provider. If you are unable to make certain of the military-related determinations
contained below in Part B, you are permitted to rely upon determinations from an authorized DOD representative
(such as a DOD recovery care coordinator). (Please ensure that Section I above has been completed before completing
this section.) Please be sure to sign the form on the last page.
Health Care Provider’s Name (Please print):
Health Care Provider’s Signature:
Date:
Address:
Phone number:
Fax number:
Specialty/Type of Practice:
Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD
TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized
health care provider: _________________________________________________________________________
revised 4/30/09
APWU FORM 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Certification By Service Member's Health Care Provider For Caregiver Military Family Leave - Fmla
Business
Certification By Service Member's Health Care Provider For Caregiver Military Family Leave - Fmla
Business
Certification Of Health Care Provider For Family Member's Serious Health Condition - Family And Medical Leave Act ("fmla") & California Family Rights Act ("cfra")
Business
Certification Of Health Care Provider For Employee's Serious Health Condition - Family And Medical Leave Act (fmla) & California Family Rights Act (cfra)
Business
Certification Of Health Care Provider For Family Member's Serious Health Condition (family Medical Leave Act)
Business
Family And Medical Leave Certification Of Health Care Provider For Family Member's Serious Health Condition - University Of Washington
Business
Certification Of Health Care Provider For Family Member's Serious Health Condition (family And Medical Leave Act)
Business
Related Categories
Parent category: Business