Form Hcpc-Fml - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 2
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4Employee Name: _________________________________________________ FMLA Claim #: _________________________________
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)? £No £Yes
If so, state the nature of such treatments and expected duration of treatment:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2) Is the medical condition pregnancy? £No £Yes If so, expected delivery date:
mm/dd/yy
3) Describe other relevant medical facts, if any, related to the condition for which the patient needs care seeks leave (Such medical facts may
include symptoms, diagnosis, or regimen of continuing treatment such as the use of specialized equipment). Note to California Physicians:
You may not disclose your patient’s underlying diagnosis without their consent.:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Part B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient's need for care by the employee
seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or
psychological care:
4) Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? £No £Yes
Estimate the beginning and ending dates for the period of incapacity:____________________________________________________
mm/dd/yy
mm/dd/yy
During this time, will the patient need care? £No £Yes
Explain the care needed by the patient and why such care is medically necessary:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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HCPC-FML (11/15) eF
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