Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family Medical Leave Act) printable pdf download

Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family Medical Leave Act)

Certification of Health Care Provider for Family Member’s Serious Health Condition

(Family Medical Leave Act)

Part A For Completion by the Employee:

Please complete this section before giving this form to your family member’s 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 benefit of FMLA protections. Failure to provide a complete and

sufficient medical certification may result in a denial or delay of your FMLA request. You have 15 calendar days to return this form

to your employer.

Name:

Employee Number:

Department:

Title:

Reports to:

Status: ___ Full‐Time ___ Part‐Time ___ Temporary

Today’s Date:

Hire Date:

Name of Family Member for whom you will provide care:

Relationship of family member to you:

If family member is your son or daughter, date of birth:

Describe care you will provide to your family member and estimate leave needed to provide care:

Employee Signature:

Date:

Part B For Completion by the HEALTH CARE PROVIDER:

Instructions: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely,

all applicable parts. 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 employee is seeking leave. Do not provide information about genetic tests, as defined in 29

C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s

family members, 29 C.F.R. § 1635.3(b). Please be sure to sign the form on the last page. Please be sure to sign the form on the last

page.

Provider’s name and business address:

Type of practice/Medical specialty:

Telephone:

Fax:

MEDICAL FACTS

1. Approximate date condition commenced:

Probable duration of condition:

Was the patient admitted for an overnight stay in a hospital,

If yes, dates of admission:

hospice, or residential medical care facility:____ Yes ____ No

Date(s) you treated the patient for condition:

Will the patient need to have treatment visits at least twice a year due to the condition? ____ Yes ____ No

Was medication, other than over‐the‐counter medication, prescribed? ____ Yes ____ No

(Continued on next page)

Created: 04/09

1 of 3

Updated 08/15

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Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family Medical Leave Act)

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