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1
2
3Employee/Patient Name: ____________________________________________________________________________________
First
Middle
Last
SECTION III: Instructions for Completion by 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.
Provider’s name and business address: (Print) ___________________________________________________________
_________________________________________________________________________________________________
Type of practice / Medical specialty: (Print) _______________________________________________________________
Telephone: ( ________ ) _____________________________ FAX :(________) _________________________________
PART A: MEDICAL FACTS
1. Medical diagnosis for which employee/patient is requesting leave: ___________________________________________
Approximate date condition commenced: _______________________________________________________________
Probable duration of condition:________________________________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No
Yes.
If so, dates of admission:__________________________________________________________________________
Date(s) you treated the patient for condition:_____________________________________________________________
______________________________________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition?
No
Yes.
Was medication, other than over-the-counter medication, prescribed?
No
Yes.
Was the patient referred to other health care provider(s) for evaluation or treatment
No
Yes
If so, state the nature of such treatments and expected duration of treatment: _______________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
2. Is the medical condition pregnancy?
No
Yes
If so, expected delivery date:_____________________________
3. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a
list of the employee’s essential functions or a job description, answer these questions based upon the employee’s own
description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition:
No
Yes
If so, identify the job functions the employee is unable to perform: ______________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Office of Human Resources | Benefits Design & Management
FMLA Certification of Health Care Provider for Employee’s Pregnancy
Page 2 of 3
Revised: August 2010
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