Form Hcpc-Fml - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 3
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4Employee Name: _________________________________________________ FMLA Claim #: _________________________________
_________________________________________________________________________________________________________
5) Will the patient require follow--up treatments, including any time for recovery? £No £Yes
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment,
including any recovery period:
_________________________________________________________________________________________________________
Explain the care needed by the patient, and why such care is medically necessary:
_________________________________________________________________________________________________________
6) Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? £No £Yes
Estimate the hours the patient needs care on an intermittent basis, if any:
___________Hour(s) per day: ___________days per week from ___________through ___________
Explain the care needed by the patient, and why such care is medically necessary:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
7) Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job Functions? £No £Yes
Is it medically necessary for the employee to be absent from work during the flare-ups? £No £Yes If so, explain:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Based upon the patient's medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration
of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency:___________ times per___________ week(s)___________ month(s)___________
Duration:____________ hours or____________ day(s) per episode
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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HCPC-FML (11/15) eF
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