Family And Medical Leave Act (Fmla) Medical Certification Form

Family and Medical Leave Act (FMLA) Certification Form

Verizon 05/08

Employee's Name: _________________________First Day of Absence _____________ BAID __________

INSTRUCTIONS : We estimate that it will take an average of ten (10) minutes to complete this form.

Please note : Incomplete Form Will Be Returned For Completion

1. Employee Complete Section A

2. Employee's Treating Health Care Provider - Complete Sections B and D

3. Family Member's Treating Health Care Provider - Complete Sections B, C, and D

SECTION A: (TO BE COMPLETED BY THE EMPLOYEE. PLEASE BE ADVISED THAT KNOWINGLY PROVIDING

FALSE OR INACCURATE INFORMATION IN THIS CERTIFICATION IS A VIOLATION OF THE COMPANY'S CODE OF

BUSINESS CONDUCT.)

Type of Leave : (check all that apply)

New Request

Extension/Recertification

On the Job Injury

Reason for Leave: (check one)

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

job.

A serious health condition affecting your spouse, child or parent for which you are needed to provide

care.

The birth of your child, or the placement of a child with you for adoption or foster care for the period

beginning ___/___/____ through ___/___/___ . You must attach documentation supporting the date of

your child's birth, or the date of foster placement or adoption.

Requested FMLA: (check all that apply)

Full Time Leave - Taken in consecutive, full day increments.

Intermittent Leave - Taken periodically over an extended period of time.

Reduced Work Schedule - Taken on consecutive days; employee is able to work some of his/her work

schedule each day.

By placing my signature below, I authorize my health care provider to (a) complete this form and (b) clarify any information

provided on the form that is incomplete or unclear, either verbally or in writing. I hereby certify that the information provided

on this certification form is true and accurate.

Signature of Employee or Family Member : _____________________________ Date : _____/_____/_____

SECTION B: (TO BE COMPLETED BY THE TREATING HCP. PLEASE NOTE: INCOMPLETE FORMS WILL BE

RETURNED FOR COMPLETION AND MAY RESULT IN DENIAL OF FMLA.)

1A. Describe the medical facts, which support your certification, including a brief statement as to how the medical facts meet

the criteria for a serious health condition under the FMLA (see page one).

___________________________________________________________________________________________________

1B. If leave is for the employee's own health condition, please describe how the health condition interferes with the

performance of essential job function(s).

___________________________________________________________________________________________________

2. This patient has been under my care for this health condition since: _____/_____/_____.

3. Does the patient's condition qualify as a serious health condition under the Family and Medical Leave Act (FMLA)? (See

page one for Family and Medical Leave Act Definitions for Health Care Providers.)

NO, the patient's condition does not qualify as a serious health condition under FMLA. (If you check this box, go directly to

Section D.)

YES, the patient's condition qualifies as a serious health condition according to the following category as described by

FMLA regulations. (Please check all that apply, and complete the applicable information.)

Please fax the completed forms to the correct processing center:

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Family And Medical Leave Act (Fmla) Medical Certification Form - Verizon West Page 3

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