Family And Medical Leave Act (Fmla) Medical Certification Form

Family and Medical Leave Act (FMLA) Certification Form

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)

Scheduled Multiple Treatments

Please answer ALL of the following questions:

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

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

The patient will receive the following treatment:

___________________________________________________________________________

_________________________________________________________________________________

Treatments will commence on ____/____/____ through ____/____/____.

The frequency of treatment is (#) ____ times per (circle one: week, month, year)

The approximate length of the appointment (including travel time) is __________ (circle one: minutes, hours,

days, weeks, months) (indicate range, if applicable)

The period required for recovery from treatment is (#) ____ (circle one: minutes, hours, days, weeks).

Pregnancy

The patient's pregnancy was confirmed on ____/____/____ with an estimated delivery date (EDC) of

____/____/____.

The patient is scheduled for approximately (#) ____ prenatal appointments.

The approximate length of the prenatal appointment is (#) ____ (circle one: minutes, hours)

Do you presently anticipate a need for the patient to be absent from work during her pregnancy?

____ Yes ____ No

If yes, please describe the medical facts that support this need: _________________________

_______________________________________________________________________________

How often do you expect this patient to be incapacitated due to this medical 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)

4. If a Reduced Work Schedule is necessary upon an employee's return to duty, please provide a description of the

required work schedule.( i.e. number of hours per day) (#) ______ from ___/___/___ through ___/___/___

SECTION C: (TO BE COMPLETED BY THE TREATING HCP IF THE LEAVE REQUEST IS TO CARE FOR A FAMILY

MEMBER. PLEASE NOTE: INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION AND MAY RESULT IN

DENIAL OF FMLA.)

Patient's Name ________________________ Relationship to Employee __________ Date of Birth ___/___/___

It is necessary for the employee to be absent from work from ___/___/___ through ___/___/___ to care for this

family member. (Please check any of the following and complete the applicable information.)

Full Time Leave - Taken in consecutive, full day increments

Follow-up appointment to Full Time Leave

Duration of the follow-up appointment, that employee needs to be away from work: (#) ____ (circle one:

minutes, hours)

Intermittent Leave - Taken periodically over an extended period of time, with a likely frequency of (#)___

-(#)____ times per (circle one: week, month, year ) with a probable duration of (#)____ (circle one:

minutes, hours, days, weeks) for a period of (#) ____ (circle one: weeks, months)

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

work schedule each day. The employee is able to work (#)____ hours per day.

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 5

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