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Family And Medical Leave Act (Fmla) Medical Certification Form - The Absence Reporting Center, Verizon Page 7

Family and Medical Leave Act (FMLA) Certification Form

Verizon 12/2012

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

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

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

6. Does the patient require assistance for:

Basic Medical or Personal Needs

Yes

Transportation

Yes

Psychological Comfort

Yes

Safety

Yes

7. If leave is required to care for a child age 18 or older, the child must be incapable of self-care. The individual must

require active assistance or supervision to provide daily self-care in three or more of the activities of daily living (ADLs) or

instrumental activities of daily living (IADLs). If the employee has requested FMLA leave to care for a child age 18 or

older, please provide at least three ADLs/IADLs that the patient requires active assistance or supervision with.

(See page

one for the definition of ADLs and IADLs.)

SECTION D: (TO BE COMPLETED BY THE TREATING HEALTH CARE PROVIDER)

We strongly recommend that you retain a copy of this form in the event clarification of its content is needed. Incomplete

forms will be returned to the employee to be completed. This may result in a delay or denial of the employee's FMLA

approval.

I certify that the above information is true and correct:

Treating Health Care Provider's Printed Name

Signature

Date

Type of Practice

Address

Phone#

Fax#

Please fax the completed forms to the correct processing center.

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Family And Medical Leave Act (Fmla) Medical Certification Form - The Absence Reporting Center, Verizon Page 7