Form Hcpc-Eml - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) - 2015 Page 3
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3Employee Name: _________________________________________________ FMLA Claim #: _________________________________
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
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mm/dd/yy
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Health Care Provider Signature
Date
Please return to the employer's FMLA administrator at:
MetLife Disability
P.O. Box 14590
Lexington, Kentucky 40512
Fax: 1-800-230-9531
Page 3 of 3
HCPC-EML (11/15) eF
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