Family And Medical Leave Act (Fmla) Medical Certification Form

Medical certification forms will NOT be accepted prior to the first day of a reported absence.

Please complete and return to:

Verizon West ( fGTE) Employees

Verizon East ( fBA N/S & VIS) Employees

The FMLA Team

The Absence Reporting Center

700 Hidden Ridge Mailcode: HQW03H65

500 Summit Lake Drive, 4

Irving, TX 75038

Valhalla, NY 10595

Fax: (214) 285-1587

Fax: 877-786-4500

Phone: (877) 275-8947

Family and Medical Leave Act (FMLA) Medical Certification Form

FMLA is a federal law that guarantees “eligible” employees up to twelve (12) workweeks of job-protected absence for certain family and medical reasons.

You are eligible to request an FMLA absence if you have worked for the company for at least one year, worked a minimum of 1250 hours over the

previous twelve (12) months, and need to be absent for one of the following reasons:

A serious health condition that makes you unable to perform any one of the essential functions of your job.

To care for your immediate family member (spouse, child, or parent) who has a serious health condition.

To care for your newborn child, or placement of an adopted or foster child.

Family and Medical Leave Act Definitions for Health Care Providers

as defined by the Department of Labor’s Regulations

Activities of daily living (ADLs): Examples include adaptive activities such as caring appropriately for one’s grooming and hygiene, bathing, dressing

and eating.

Health Care Provider (HCP): Authorized health care providers include any of the following who are authorized to practice under State law, and who are

practicing within the scope of that practice: doctors of medicine or osteopathy, podiatrists, dentists, clinical psychologists, optometrists and chiropractors,

nurse practitioners, nurse-midwives, clinical social workers, and any other person determined by the Secretary of Labor to be capable of providing health

care services.

Incapacity: The inability to work or perform regular daily activities due to the patient's serious health condition, treatment for that condition, or recovery

from that condition.

Instrumental activities of daily living (IADLs): Activities include cooking, cleaning, shopping, paying bills, maintaining a residence, using a post office

and telephone.

Regimen of Continuing Treatment: Treatment including, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring

special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the-counter medications such

as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care

provider.

Serious Health Condition: An illness, injury, impairment, or physical or mental condition that meets one of the following criteria:

1. Hospital Care: Inpatient care (e.g. 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 inpatient care.

2. Absence Plus Treatment (Acute): 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:

(A) Two or more treatments by an HCP or by a nurse or physician's assistant under direct supervision of an HCP, or by a

provider of health care services (e.g., physical therapist) under orders of, or on referral by, an HCP; or

(B) At least one treatment by an HCP which results in a regimen of continuing treatment under the supervision of the HCP.

3. Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care.

4. Chronic Health Condition Requiring Treatments: A chronic condition which:

(A) Requires periodic visits for treatment by an HCP, or by a nurse or physician's assistant under direct supervision of an HCP;

(B) Continues over an extended period of time; and

5. Permanent/Long Term Conditions Requiring Supervision: A period of incapacity which is permanent or long term due to a condition for

which treatment may not be effective, e.g. Alzheimer's, a severe stroke. The patient must be under the continuing supervision of, but need not

be receiving active treatment by, an HCP.

6. Scheduled Multiple Treatments: Any period of absence to receive scheduled multiple treatments (including any period of recovery) by an

HCP or by a provider of health care services under orders of, or on referral by, an HCP, either for restorative surgery after an accident or other

injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of

medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Treatment: Includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine

physical examinations, eye examinations, or dental examinations.

Please fax the completed forms to the correct processing center:

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