Family And Medical Leave Act (Fmla) Medical Certification Form - The Absence Reporting Center, Verizon

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20-1923 (12-2012)
Dear Employee,
You may be eligible for leave under the Family and Medical Leave Act (FMLA) as described in the attachment, "Employee
Rights and Responsibilities Under the Family and Medical Leave Act", and applicable state laws. The enclosed materials
describe your rights and obligations under FMLA. The company will comply with any state laws and contractual bargaining
agreements. In order to be approved for FMLA, you must complete and submit the enclosed Family and Medical Leave Act
(FMLA) Medical Certification Form. It is your responsibility to ensure that your completed form is received by our office, via
fax or mail, within 25 calendar days of your first day of absence or 25 calendar days from the date the absence was reported.
Note that you may apply for leave on an intermittent basis or reduced schedule. Section B of the form covers this. Please
allow for appropriate mail time. We strongly recommend that you retain a copy of the application and proof of mailing/ faxing
for your records. Please remember that it is your responsibility to follow-up with your health care provider to ensure the
completed form is received by our office. Fees charged by health care provider for completion, copying or faxing of the
FMLA Medical Certification Forms are the responsibility of the employee.
If approved:
Your leave will be counted against your 12 weeks per calendar year FMLA leave entitlement.
Your FMLA leave may run concurrent with any periods of approved payments under any applicable plan, policy,
program, or collective bargaining agreement.
Recertification may be required if your leave exceeds the period designated by the health care provider. When
applying for intermittent leave for a health condition which is chronic or requires periodic treatments or a reduced
leave schedule, please be certain that your health care provider indicates the duration and frequency of the leave
required on the Family and Medical Leave Act (FMLA) Medical Certification Form.
If you fail to return to work upon the expiration of your FMLA leave, and you have not obtained any other type of
approved leave, the company may treat your failure to return as a voluntary resignation, unless your absence has
been approved under the provisions of the Sickness and Accident Disability Benefit Plan.
Your FMLA request may be denied, and therefore, the absence may be subject to the provisions of the established
attendance plan and practices in your area, if:
The completed form is not received by our office within 25 calendar days from the first day of absence or 25 calendar
days from the date the absence was reported.
The information provided by your health care provider regarding your health condition does not establish a serious
health condition under FMLA regulations.
Your absence exceeds your remaining FMLA time.
If your absence is approved under the applicable disability plan within 39 days from the date the absence was reported into
AMTS, the absence will also be approved under FMLA. However, you will not have another opportunity to apply for FMLA
leave for this absence if your short term disability is not approved within this 39 day period.
If you have any questions, please contact the FMLA Administrator at 1-855-814-9344 or visit the Verizon e-web and search
for FMLA.
Please fax the completed forms to the correct processing center.
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