Medical Certification For Employee'S Serious Health Condition printable pdf download

Medical Certification For Employee'S Serious Health Condition

Certification of Health Care Provider for Employee’s Serious Health Condition

(UNMH Policy 175 – Family and Medical Leave)

Section I. For Completion by the EMPLOYEE.

INSTRUCTIONS TO EMPLOYEE: Please complete Section I before giving this form to your medical

provider. UNMH requires that you submit a timely, complete, and sufficient medical certification to

support a request for FMLA leave due to your own serious health condition. Failure to provide timely,

complete, and sufficient medical certification may result in denial of your FMLA request.

Employee Name:______________________________________________________________________

Job Title: ____________________________________________________________________________

Regular Work Schedule: ________________________________________________________________

Essential Job Functions or attach your job description: ________________________________________

___________________________________________________________________________________

Check if the job description is attached:  Yes  No

Section II. For Completion by the HEALTHCARE PROVIDER.

INSTRUCTIONS TO HEALTHCARE PROVIDER: Your patient has requested leave under the FMLA.

Answer all applicable parts fully and completely. Several questions seek a response as to the

frequency and 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” will not be sufficient to determine

FMLA coverage. Limit your response to the condition for which the employee is seeking leave.

Please be sure to sign and date the form on the last page.

Provider’s Name & Business Address: ____________________________________________________

Type of Practice / Medical Specialty: ______________________________________________________

Telephone: ______________________________ Fax:________________________________________

PART A. MEDICAL FACTS

1. Approximate date the condition commenced: ____________________________________________

Probable duration of the 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 yes, dates of admission:

________________________________________________________________________________

Date(s) you treated the patient for the condition:

________________________________________________________________________________

Will the patient need to have treatment at least twice per year due to the condition? No Yes

Was medication, other than over-the-counter medication, prescribed? No Yes

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Medical Certification For Employee'S Serious Health Condition