Form Hcpc-Fml - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act)
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4Employee Name: _______________________________________________ FMLA Claim #: _________________________________
Certification of Health Care Provider for Family Member's Serious Health Condition
(Family and Medical Leave Act)
Please complete Section I before giving this form to your family member or his/her 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 to care for a covered family member
with a 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
Name of family member for whom you will provide care:_________________________________________________________________
First
Middle
Last
Relationship of family member to you:_______________________________________________________________________________
mm/dd/yy
If family member is your son or daughter, date of birth:________________________________________________________
Describe the care you will provide to your family member and estimate leave needed to provide care:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
mm/dd/yy
___________________________________________________________________
______________________________________
Employee Signature
Date
SECTION II: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTHCARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer,
fully, and completely, all applicable parts below. 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 patient needs leave. Page 2 provides for additional information, should you need it. 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
mm/dd/yy
1) Approximate date condition commenced:_________________________________________________________________________
Probable duration of condition:_________________________________________________________________________________
Page 1 of 4
HCPC-FML (11/15) eF
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