Family And Medical Leave Act (Fmla) Medical Certification Form - Verizon West Page 7
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8Fax Cover Sheet
Medical certification forms will NOT be accepted prior to the first day of a reported absence.
Employees please ensure to send the FMLA forms to the correct Processing Center
:
Verizon West ( fGTE) Employees
Verizon East ( fBA N/S & VIS) Employees
FMLA Team
Absence Reporting Center
th
700 Hidden Ridge Mailcode:HQW03H65
500 Summit Lake Drive 4
Fl
Irving, TX 75038
Valhalla, NY 10595
FAX 214-285-1587
FAX 1-877-786-4500
Employee Name: __________________________
First Day of Absence: ________________
Date: ______________________________
Fax#:______________________________
From: ______________________________
Pages including cover sheet: ___________
CONFIDENTIAL AND PRIVATE
Please fax the completed forms to the correct processing center:
Page 7 of 8
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