Family And Medical Leave Act (Fmla) Medical Certification Form

Dear Employee,

20-1923

(05-08)

You may be eligible for leave under the Family and Medical Leave Act (FMLA) as described in the attachment, "Your Rights Under the Family and

Medical Leave Act of 1993", and applicable state laws. The enclosed materials describe your rights and obligations under FMLA. The company will

comply with any state laws and contractual bargaining agreements. In order to be approved for FMLA, you must complete and submit the enclosed

Family and Medical Leave Act (FMLA) Medical Certification Form.

Note that you may apply for leave on an intermittent basis or reduced schedule. Section B of the form covers this. It is your responsibility to ensure that

your completed form is received by our office, via fax or mail, within 25 days of your first day of absence or 25 days from the date the absence was

reported. Please allow for appropriate mail time. We strongly recommend that you retain a copy of the application and proof of mailing/ faxing for your

records. The Family and Medical Leave Act (FMLA) Medical Certification Form must be completed by:

Your health care provider - if you are requesting an absence for yourself due to a serious health condition.

Your family member's health care provider - if you are requesting an absence to care for a family member with a serious health condition.

Yourself - if you are requesting an absence to care for a newborn under twelve months old, or for the placement of a child with you for adoption

or foster care. Please also provide proof of birth or placement.

Fees charged by health care provider for completion, copying or faxing of the Family and Medical Leave Act (FMLA) Medical Certification Forms are the

responsibility of the employee.

We will notify you of the status of your FMLA request after receiving and reviewing the completed Family and Medical Leave Act (FMLA) Medical

Certification Form. Generally, you should receive written notice of the approval or denial of FMLA leave for this absence within approximately a week

from receipt of your completed form.

If approved:

The period of your approved leave will be counted toward your twelve (12) workweek FMLA allotment, and state allotment, if applicable.

Your FMLA leave will run concurrent with any periods of approved payments under any applicable plan, policy, program, or collective

bargaining agreement.

If you are not entitled to payment during FMLA leave, you may supplement your leave with other available paid time off, such as vacation or

personal days.

Recertification will be required if your leave exceeds the period designated by the health care provider. When applying for intermittent leave

for a health condition which is chronic or requires periodic treatments or a reduced leave schedule, please be certain that your health care

provider indicated the duration of the leave required on the Family and Medical Leave Act (FMLA) Medical Certification Form.

If you fail to return to work upon the expiration of your FMLA leave, and you have not made any alternative arrangements, the company

may treat your failure to return as a voluntary resignation, unless your absence has been approved under the provisions of the Sickness

and Accident Disability Benefit Plan.

Your FMLA request may be denied, and therefore, the absence may be subject to the provisions of the established attendance plan and practices in

your area, if:

The completed form is not received by our office within 25 days (calendar days) from the first day of absence or 25 days (calendar days)

from the date the absence was reported.

The information provided by your health care provider regarding your health condition does not establish a serious health condition under

FMLA regulations.

Your absence exceeds your remaining FMLA entitlement.

Please remember that it is your responsibility to follow-up with your health care provider to ensure the completed form is received by our office within

25 days from the first day of absence or 25 days (calendar days) from the date the absence was reported. You are responsible for communicating

with your Supervisor/ Absence Administrator during your absence period.

If your absence is approved under the applicable disability plan within 39 days from the date the absence was reported into AMTS, the absence will

also be approved under FMLA. However, you will not have another opportunity to apply for FMLA leave for this absence if your short term disability is

not approved within this 39 day period. Accordingly, to ensure that your absence is considered for FMLA leave coverage, you must return a

completed FMLA Medical Certification Form within the time frame specified.

If you have any questions, please contact the FMLA Administrator at (877) 275-8947 or visit the Verizon eweb and search for fmla.

Family And Medical Leave Act (Fmla) Medical Certification Form - Verizon West

Related Articles

Related forms

Related Categories