Honorhealth Leave Of Absence Request Form For Medical, Maternity, Family Or Military


Leave of Absence Request
For Medical, Maternity, Family or Military
immediately to Employee Benefits.
Then, have the
appropriate medical certification completed by the treating
Leave of Absence
physician. It is your responsibility to ensure that Employee
Leave of absence is used to document and authorize time
Benefits receives all completed forms. DO NOT SUBMIT
away from work for surgery, in-patient admission, or in excess
of seven calendar days for medical leave or family care leave.
This includes the need for intermittent and reduced-schedule.
What happens after I submit my request?
You will receive a letter letting you know whether you are
Family Medical Leave Act
eligible for leave under the FMLA and whether your
The Family Medical Leave Act (FMLA) gives an eligible staff
absences qualifies as job-protected leave under the
member the right to take up to 12 weeks of unpaid job-
protected leave in a 12-month period. Leave can be for the
birth/adoption of a child, to care for a spouse, parent, or child
Will I be paid during my leave?
with a serious health condition; or when the staff member is
While on medical leave:
unable to work because of their own serious health condition.
 PTO may be used to supplement payment of STD
In addition, an eligible staff member may take up to 26 weeks
benefits which are processed by Mutual of Omaha.
of unpaid job-protected leave for military caregiver leave.
However, the combined total of STD and PTO may not
exceed 100% of regular wages. You are responsible for
To be eligible, a staff member must complete 12-months of
employment and have worked at least 1,250 hours during the
supplemental PTO can be entered on your timecard for
12-months immediately before the start of the leave.
 WC payments will be paid through HonorHealth’s claim
administrator and PTO cannot be used.
The FMLA entitlement is determined by a rolling 12-month
period measured backwards from the date a staff member
uses family leave or medical leave.
While on a family (including maternity), personal or
educational leave:
 PTO will be used and the amount of PTO used must be
FMLA runs concurrently with any paid leave offered by
the same as normal scheduled work hours.
HonorHealth such as Paid Time Off (PTO), Short-Term
Disability (STD), Workers’ Compensation (WC). All days away
While on military leave:
from work (including intermittent absences, reduced schedule
 See policy HR1077 Military Deployment and Vaccines
leave) will be counted toward the staff member’s FMLA
for Military Personnel.
Is my job protected?
Periodic Reporting Requirements
If you are not eligible for job-protected leave under the
While on leave, you may be required to furnish Employee
FMLA, your position may be posted and filled. If you are
Benefits with periodic written reports of your status and intent
eligible for FMLA, your job is protected during the first
to return to work.
cumulative 12-week period while you are on a qualifying
FMLA leave. If you remain off work beyond 12 weeks,
A Medical Certification is required to support a staff member’s
your position may be filled permanently. Please discuss
medical leave and must be completed by a physician. Family
the status of your position with your department manager.
Certification of Serious Health Condition from Health Care
If your position is not available when you are cleared to
return to work, you may have up to 30 days to work with
Recruiting to find another position for which you qualify. If
Return to Work
a position is not secured within 30 calendar days, your
If your medical (including maternity) condition keeps you off
employment with HonorHealth will be separated.
work more than 7 calendar days, you must take a copy of the
How will my HonorHealth group health insurance
written release from your treating physician to Corporate
Health for drug testing and final clearance to return to work.
premiums be paid?
The urine drug test may be conducted up to 14 days prior to
When you are not receiving a paycheck from
HonorHealth you will be responsible for the cost of
your scheduled return to work date. We recommend allowing
sufficient time to be cleared by Corporate Health.
benefit premiums. You will receive instructions on how
to pay your premiums in a separate letter. Premiums you
Return to work from a family (other than maternity), military or
pay will be based on your years of service:
personal leave does not require a urine drug screen.
More than one year of service – you will be
responsible for the benefit premiums
Question & Answer
deducted from your payroll checks for you (and your
dependents) for a maximum period of 6 months.
How do I apply for a Leave of Absence?
Complete a Leave of Absence Request and Authorization
Less than one year of service, you will be responsible
to Release Information (if applicable). Submit forms
for the total cost of benefit premiums when your leave
extends beyond two unpaid pay periods.
) & HR1073 (F
Rev January 2013- Medical, Family, Military


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