Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) (Page 2 of 3) in pdf

Employee Name: ______________________________

PATIENT Name: __________________________________

SECTION 3: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS:

The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all

applicable parts below. 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

patient needs leave. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. §

1635.3(e). Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page.

Please be sure to sign the form on the last page.

Provider’s name and business address: __________________________________________________________________

Type of practice / Medical specialty: ____________________________________________________________________

Telephone: (________) _________________________________Fax :(_________) ______________________________

PART A: MEDICAL FACTS

1. Approximate date condition commenced: ______________________________________________________________

Probable duration of condition: ________________________________________________________________________

Mark below as applicable:

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: ______________________________________________________________

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: ______________________________________________________

Was medication, other than over-the-counter medication, prescribed? ___No ___Yes.

Will the patient need to have treatment visits at least twice per year due to the condition? ___No ____ Yes

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?

____ No ____Yes.

If yes, 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. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical

facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

__________________________________________________________________________________________________

Page 2 of 3

Rev 02 25 2016

Certification Of Health Care Provider For Family Member'S Serious Health Condition (Family And Medical Leave Act) Page 2

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