Form Cfn 552-0755 - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) - Iowa Department Of Administrative Services

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Certification of Health Care Provider for Employee’s
Serious Health Condition (Family and Medical Leave Act)
SECTION I: For Completion by the EMPLOYER:
Instructions to the Employer:
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee
seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the
employee’s health care provider. Please complete Section I before giving this form to your employee. You may not ask the employee
to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally
maintain records and documents relating to medical certifications, recertifications, or medical histories of employees created for FMLA
purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. §
1630.14(c)(1), if the Americans with Disabilities Act applies.
Employer name and contact:
_______________________________________________________________________
Employee’s job title:
____________________________
Regular work schedule:
__________________________
Employees’ essential job functions:
__________________________________________________________________
_________________________________________________________________________________________________
Check if job description is attached:
SECTION II: For Completion by the EMPLOYEE:
Instructions to the Employee:
Please complete Section II before giving this form to your medical provider. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to
your own serious health condition. If certification is requested, your response is required to obtain or retain the benefit of FMLA
protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of
your FMLA request. 20 C.F.R. § 825.313. You must be allowed least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name:
________________________
________________________
________________________
First
Middle
Last
SECTION II: For Completion by the HEALTH CARE PROVIDER:
Instructions to the Health Care Provider:
Your patient has requested leave under the FMLA. Answer, fully and completely, all
applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer
should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific
as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your
responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.
To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. “Genetic Information” as defined by GINA includes an individual’s family medical history, the results of an individual’s or
family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
Provider’s name and business address:
______________________________________________________________
Type of practice/Medical specialty:
______________________________________________________________
Telephone:
(____) ____________________________________
Fax:
(____) __________________________
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CFN 552-0755 10/11

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