Form Hcpc-Eml - Certification Of Health Care Provider For Employee'S Serious Health Condition (Family And Medical Leave Act) - 2015 Page 2
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3Employee Name: _________________________________________________ FMLA Claim #: _________________________________
£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 deliver date:
mm/dd/yy
3) 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:
_________________________________________________________________________________________________________
4) 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). Note to California Physicians: You
may not disclose your patient’s underlying diagnosis without their consent.:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Part B: AMOUNT OF LEAVE NEEDED
5) Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment
and recovery? £No £Yes If so, estimate the beginning and ending dates for the period of incapacity:
_________________________________________________________________________________________________________
mm/dd/yy
mm/dd/yy
6) Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee's
medical condition? £No £Yes
If so, are the treatments or the reduced number of hours of work medically necessary? £No £Yes
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment,
including any recovery period:
_________________________________________________________________________________________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
___________Hour(s) per day: ___________days per week from ___________through ___________
7) Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? £No £Yes
Is it medically necessary for the employee to be absent from work during the flare-ups? £No £Yes If so, explain:
_________________________________________________________________________________________________________
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
Page 2 of 3
HCPC-EML (11/15) eF
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