Family And Medical Leave Act (Fmla) Medical Certification Form

Family And Medical Leave Act (Fmla) Medical Certification Form - Verizon West Page 6

Family and Medical Leave Act (FMLA) Certification Form

Employee's Name: ________

First Day of Absence ______________ BAID _______________

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

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

6. Does the patient require assistance for :

Basic Medical or Personal Needs

Transportation

Yes

Psychological Comfort

Safety

Yes

If leave is required to care for a child age 18 or older, the child must be incapable of self-care. The individual

must require active assistance or supervision to provide daily self-care in three or more of the activities of daily

living (ADLs) or instrumental activities of daily living (IADLs). If the employee has requested FMLA leave to care

for a child age 18 or older, please provide at least three ADLs/IADLs that the patient requires active assistance

or supervision with. (

)

See page one for the definition of ADLs and IADLs.

___________________________________________________________________________________

SECTION D: (TO BE COMPLETED BY THE TREATING HEALTH CARE PROVIDER.)

We strongly recommend that you retain a copy of this form in the event clarification of its content is needed.

Incomplete forms will be returned to the employee to be completed. This may result in a delay or denial of the

employee's FMLA approval.

I certify that the above information is true and correct :

___________________________________________________________________________________

Treating Health Care Provider's Printed Name

Signature

Date

__________________________________________________________________________________________

Type of Practice

Address

Phone#

Fax#

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 6