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Medical Certification Of Health Care Provider For Employee'S Serious Health Condition Form - Montgomery County Government

MCPR, 2001

APPENDIX P-1, FMLA FORM – EMPLOYEE SERIOUS HEALTH CONDITION

Montgomery County Government

Medical Certification of Health Care Provider for

Employee’s Serious Health Condition Form

(Family and Medical Leave Act of 1993 as amended)

SECTION I: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your medical

provider. The Family and Medical Leave Act (FMLA) provides that an employer may require an employee

seeking FMLA leave for the employee’s serious health condition to submit a timely and complete

certification providing sufficient facts to support the request for leave. Your response is required to obtain or

retain the benefit of FMLA-protected leave. Failure to do so may result in a denial of your FMLA request.

You have 15 calendar days to return this form to your supervisor.

Your name: _____________________________________________________________________________

First

Middle

Last

Your department/division ________________________________________________________

Your job title: _____________________________ Your regular work schedule: ______________________

Your supervisor: ________________________________

Your essential job functions: ________________________________________________________

_______________________________________________________________________________________

Check if job description is attached: _____

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. Page 4 provides space for additional

information, should you need it. Please be sure to sign the form on the last page.

Provider’s name and business address: ________________________________________________________

Type of practice / Medical specialty: _________________________________________________________

Telephone: (________) _____________________________ Fax :(_________) _______________________

P – 1-1

Medical Certification Of Health Care Provider For Employee'S Serious Health Condition Form - Montgomery County Government