City Of Dallas Family Medical Leave Application Form (Page 3 of 5) in pdf

City of Dallas

FAMILY MEDICAL LEAVE APPLICATION

HEALTHCARE PROVIDER CERTIFICATION – Part II

(The treating physician is responsible for completing this section.)

Employee Name:

Patient's Name (If Different):

Serious Health Condition

DIAGNOSIS: ______________________________________________________________________

Provide the medical facts that describe the patient’s illness/condition supporting your certification. Include a brief statement as to how the

medical facts meet the criteria of the applicable Serious Health Condition(s) as defined below. (If more space is needed, use the back of

this page.)

CHECK ONE OR MORE OF THE APPLICABLE SERIOUS HEALTH CONDITION(S) AS DEFINED BELOW:

1. Hospital Care

Hospital care is in-patient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including

any period of incapacity or subsequent treatment** in connection with or consequent to such in-patient care.

2. Absence Plus Treatment

Absence plus treatment is a period of incapacity of more than three consecutive calendar days (including any subsequent

treatment or period of incapacity relating to the same condition), that also involves:

1. Treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision

of a healthcare provider, or by a provider of healthcare services (e.g., physical therapist) under orders of, or on

referral by, a healthcare provider; or

2. Treatment by a healthcare provider on at least one occasion which results in a regimen of continuing treatment***

under the supervision of the health provider.

3. Pregnancy

Any period of incapacity due to pregnancy, prenatal care or bonding with newborn.

4. Chronic Conditions Requiring Treatments

A chronic condition which:

1. Requires periodic visits for treatment by a healthcare provider, or by a nurse or physician’s assistant under direct

supervision of healthcare provider;

2. Continues over an extended period of time (including recurring episodes of a single underlying condition); and

3. May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).

5. Permanent/Long-term Conditions Requiring Supervision

A permanent/long-term condition requiring supervision is a period of incapacity which is permanent or long-term due to a

condition for which treatment may not be effective. The employee or family member must be under the continuing

supervision of, but need not be receiving active treatment by, a healthcare provider. Examples include Alzheimer’s, a

severe stroke, or the terminal stages of a disease.

“Dallas, the City that Works: Diverse, Vibrant and Progressive”

HRD Form Rev.June 2006

City Of Dallas Family Medical Leave Application Form Page 3