Looking for a Fmla Certification Form Templates? Download it for free!

Family and Medical Leave Act (FMLA) Certification Form

Verizon 12/2012

Employee's Name: _________________________First Day of Absence _____________ EMPLID __________

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

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

Question 3 (cont'd)

d)  Scheduled Multiple Treatments

Please answer ALL of the following questions:

 First Day incapacitated for this current incident: ____/____/____

 Last Day incapacitated for this current incident: ____/____/____

 The patient will receive the following treatment:

 Treatments will commence on ____/____/____ through ____/____/____.

 The frequency of treatment is (#) ____ times per (circle one: week, month, year)

 The approximate length of the appointment (including travel time) is __________ (circle one: minutes, hours,

 days, weeks, months) (indicate range, if applicable)

 The period required for recovery from treatment is (#) ____ (circle one: minutes, hours, days, weeks).

e)  Pregnancy

 The patient's pregnancy was confirmed on ___/___/____ with an estimated delivery date (EDC) of ___/___/____

 The patient is scheduled for approximately (#) ____ prenatal appointments.

 The approximate length of the prenatal appointment is (#) ____ (circle one: minutes, hours)

 Do you presently anticipate a need for the patient to be absent from work during her pregnancy?

____ Yes ____ No

 If yes, please describe the medical facts that support this need: _________________________

_______________________________________________________________________________

 How often do you expect this patient to be incapacitated due to this medical condition? (indicate range,

if applicable)

(

#) ____ times per (circle one: week, month, year) each lasting (indicate range, if applicable)

(#) ____ (circle one: minutes, hours, days, weeks) for a period of (#) ____ (circle one: weeks, months)

4. If a Reduced Work Schedule is necessary upon an employee's return to duty, please provide a description of the

required work schedule.( i.e. number of hours per day) (#) ______ from ___/___/___ through ___/___/___.

SECTION C: (TO BE COMPLETED BY THE TREATING HCP IF THE LEAVE REQUEST IS TO CARE FOR A FAMILY

MEMBER. PLEASE NOTE: INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION AND MAY RESULT IN

DENIAL OF FMLA.)

Patient's Name ________________________ Relationship to Employee __________ Date of Birth ___/___/___

5. It is necessary for the employee to be absent from work from ___/___/___ through ___/___/___ to care for this family

member. (Please check any of the following and complete the applicable information.)

Full Time Leave - Taken in consecutive, full day increments

Follow-up appointment to Full Time Leave: ___________________________________________

Duration of the follow-up appointment, that employee needs to be away from work: (#) ____ (circle one: minutes, hours)

Intermittent Leave - Taken periodically over an extended period of time, with a likely frequency of (#)___ to

(#)____ times per (circle one: week, month, year ) with a probable duration of (#)____ (circle one: minutes, hours,

days, weeks) for a period of (#) ____ (circle one: weeks, months)

Reduced Work Schedule -Taken on consecutive days; the employee is able to work some of his/her work

schedule each day. The employee is able to work (#)____ hours per day.

Please fax the completed forms to the correct processing center.

Page 6 of 9

Family And Medical Leave Act (Fmla) Medical Certification Form - The Absence Reporting Center, Verizon Page 6

Related Articles

Related forms

Related Categories