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

Employee Name: ______________________________

PATIENT Name: __________________________________

PART B: AMOUNT OF LEAVE NEEDED

4. Will the patient be incapacitated for a single continuous period of time due to his/her medical condition including any

time for treatment and recovery? ___No ___Yes.

Estimate the beginning and ending dates for the period of incapacity: ____/____/____ ____/____/____

During this time will the patient need care? ___No ___Yes.

Explain the care needed by the patient and why such care is medically necessary:

____________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Will the patient require follow-up treatments, including any time for recovery? ___No __Yes.

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each

appointment, including any recover period:

_________________________________________________________________________________________________

Explain the care needed by the patient during treatment schedule and why such care is medically necessary:

_________________________________________________________________________________________________

6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?

___No ___ Yes.

Estimate the hours the patient needs care on an intermittent basis, if any:

__________hour(s) per day; _________ days per week from ____/____/____ through ____/____/____

Explain the care needed by the patient on this intermittent basis and why such care is medically necessary:

_____________________________________________________________________________________________________________________________________________________

7. Will the condition cause episodic flare-ups periodically preventing the patient from performing normal daily activities?

____No ____Yes.

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-

ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months

lasting 1-2 days):

Frequency: _____ times per _____ week(s) _____ month(s)

Duration: _____ hours or ___ day(s) per episode

__________________________________________

Signature of Health Care Provider

Date

PLEASE RETURN COMPLETED FORM TO:

Carolyn Bosley

Leave Management Administrator

Appalachian State University

Phone: (828) 262-6488

ASU Box 32010

Fax:

(828) 262-6489

Boone, NC 28608

SECTION 4: For Completion by Appalachian State University Human Resource

FML is applicable in this case: _____YES _____ NO

Approved by: __________________________________

Designation Letter ____/____/____

Page 3 of 3

Rev 02 25 2016

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

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