Form Hcpc-Fml - Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 4

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Employee Name: _________________________________________________ FMLA Claim #: _________________________________
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mm/dd/yy
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 4 of 4
HCPC-FML (11/15) eF

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