Form Hcpc-Eml - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) - 2015

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Employee Name: _________________________________________________ FMLA Claim #: _________________________________
Certification of Health Care Provider for Employee's Serious Health Condition
(Family and Medical Leave Act)
Please complete Section I before giving this form to your 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 due to your own serious health condition. If requested by your
employer, your response is required to obtain or retain the benefits of FMLA protections. Failure to provide a complete and sufficient medical
certification may result in a denial of your FMLA request.
SECTION I: For Completion by the EMPLOYEE
Your Name: __________________________________________________________________________________________________
First
Middle
Last
SECTION II: For Completion by the HEALTH CARE PROVIDER
Your patient has requested leave under the FMLA, Answer, fully and completely, all applicable parts. 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 employee is seeking leave Please be sure to sign the form on the
last page.
NOTE TO ALL HEALTH CARE PROVIDERS: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other
entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except
as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to
this request for medical information. ‘Genetic Information’ as defined by GINA, includes an individual’s family medical history, the results of an
individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services,
and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.
Provider's name and business address: ______________________________________________________________________________
Type of practice / Medical specialty:_________________________________________________________________________________
Telephone: (
) _______________________  Fax: (
) _______________________
Part A: Medical Facts
1) Approximate date condition commenced: _________________________________________________________________________
mm/dd/yy
Probable duration of 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 so, dates of admission:
_________________________________________________________________________________________________________
For employees working in California only:
Was the patient formally admitted to a medical facility with the expectation that he or she would remain at least overnight and occupy a
bed, even if it later developed that the patient could be discharged or transferred and did not spend the night?
£No £Yes If so, dates of admission:
_________________________________________________________________________________________________________
Date(s) you treated the patient for condition:
_________________________________________________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition? £No £Yes
Was the medication, other than over-the-counter medication, prescribed? £No £Yes
Was the patient referred to the other health care provider(s) for evaluation or treatment (e.g. physical therapist)?
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HCPC-EML (11/15) eF

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