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 _______________

SECTION B - continued: (TO BE COMPLETED BY THE TREATING HCP. PLEASE NOTE: INCOMPLETE

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

Question 3 (cont'd)

Hospital Care (Inpatient – overnight stay)

Please answer ALL of the following questions:

First Day incapacitated for this current episode: ____/____/____

Last Day incapacitated for this current episode: ____/____/____

Admit Date: ____/____/____ Discharge Date: ____/____/____

Follow-up Appointment Date(s): ______________________________________

If employee needs to be absent from work for follow-up appointment(s), please indicate the

duration of the follow-up appointment(s): (#)_______(circle one: minutes, hours)

Absence Plus Treatment (Acute)

Please answer ALL of the following questions:

First Day incapacitated for this current episode: ____/____/____

Last Day incapacitated for this current episode: ____/____/____

The patient's period of incapacity exceeded three (3) consecutive calendar days and involved treatment two

(2) or more times by the health care provider, or treatment on at least one occasion which resulted in a

regimen of continuing treatment. If a regimen of continuing treatment is required under your supervision,

provide a general description of the regimen (e.g., prescribed medication, physical therapy):

_________________________________________________________________________

Follow-up appointment date(s): ___________________________________________

If employee needs to be absent from work for follow-up appointment(s), please indicate the duration

of the follow-up appointment(s): (#)_______ (circle one: minutes, hours)

Chronic Condition Requiring Treatment/ Permanent Long Term Condition Requiring

Supervision

The patient requires periodic visits to the health care provider for treatment, the condition continues

over an extended period of time, and the condition may cause episodic rather than a continuing

period of incapacity. The patient requires the following treatment including prescribed medication,

examinations and/or evaluations of the condition:

___________________________________________________________________________

Please complete ALL of the following questions that apply:

Current Absence

Period of incapacity for this absence : From ____/____/____ Through : ____/____/____

Future Intermittent Absences (Please complete the following information.)

How often do you expect this patient to be incapacitated due to their health condition?

(indicate range, if applicable) (#)______ times per (circle one: week, month, year) each lasting

(indicate range, if applicable) (#)______ (circle one: minutes, hours, days, weeks) for a period of

(#)______(circle one: weeks, months)

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 4