CERTIFICATION OF HEALTH CARE PROVIDER for LEAVE REQUESTS because of EMPLOYEE00 OWN SERIOUS HEALTH CONDITION
This must be fully completed by Health Care Provider to determine whether absence from work will be excused.
Employee00 Name (printed)
Employee00 Agency
Check the appropriate definition and answer any questions for the serious health condition that apply: Serious Health Condition means an illness, injury, impairment, or physical or mental condition that involves one of the following:
! (1) Inpatient Hospital Care, including any period of incapacity or subsequent treatment consequent thereto.
Date admitted to Hospital Date released from Hospital
*IF DATES OF INCAPACITY DIFFER FROM DATES OF HOSPITALIZATION, AND/OR CONTINUING TREATMENT IS NEEDED, PLEASE ALSO CHECK #2 AND COMPLETE THE INFORMATION REQUESTED. ! (2) Absence Plus Treatment A period of incapacity of more than three consecutive calendar days that also involves treatment by a health care provider on at least one occasion during the incapacity which results in a regimen of continuing treatment under the supervision of the health care provider. Date incapacity began Date employee able to return to work Date(s) of treatment(s) during incapacity Any restrictions? !Yes !No If yes, specifically identify any job duties employee will not be able to perform AND the duration of any such inability:
If future treatment is needed after employee returns to work, list date(s) of such treatment(s) if scheduled:
If future treatment is needed but appointments are not yet scheduled: Estimate probable number of treatments needed between now and June 30 (end of fiscal year for FMLA leave)
Estimate how frequently treatments will be needed (e.g. weekly, monthly, other interval)
Were prescription medications prescribed for employee for this condition? ! Yes ! No
State the medical facts of the employee00 condition which support your certification including a brief statement as to how the medical facts meet the criteria:
! (3) Pregnancy Any period of incapacity due to pregnancy or for prenatal care. Dates of / Intervals between Prenatal Visits Est. Delivery Date (EDD) If employee is incapacitated prior to EDD: Date incapacity began Date employee able to return to work Any restrictions? !Yes !No If yes, specifically identify any job duties employee will not be able to perform AND the duration of any such inability:
! (4) Chronic Conditions Requiring Treatments If condition is chronic 00go to Pages 3 & 4; completion is required.
! (5) Permanent/Long-term Conditions Requiring Supervision 00(e.g. Alzheimer00, a severe stroke, or the terminal stages of a disease)
State the medical facts of the employee00 condition which support your certification including a brief statement as to how the medical facts meet the criteria:
! (6) Multiple Treatments (Non-Chronic Conditions) 00(e.g. chemotherapy, physical therapy, dialysis)
State the medical facts of the employee00 condition which support your certification including a brief statement as to how the medical facts meet the criteria:
List dates of / Intervals between treatments and duration of incapacity during recovery time, if any, from each treatment:
! (7) None of the above Non-eligible medical conditions include (but are not limited to): taking over-the-counter medications, bed-rest, drinking plenty of fluids, or any similar activities that can be initiated without a visit to a health care provider unless something more serious is involved. The common cold, flu, ear aches, upset stomach, minor ulcers, headaches (other than migraines), routine dental problems, and periodontal diseases are conditions that do not qualify for family-medical leave. Cosmetic treatments and plastic surgery are not serious health conditions unless inpatient hospital care is required or complications develop. Family-medical leave may not be used for short-term conditions for which treatment and recovery are brief, such as minor illnesses and out-patient surgical procedures with expected brief recuperating periods.
The undersigned hereby certifies that the above information is true and accurate. Signature of Health Care Provider
Type of Practice / Name of Group
Printed Name
Address
Date completed Phone Fax
CERTIFICATION OF HEALTH CARE PROVIDER for INTERMITTENT LEAVE REQUESTS because of EMPLOYEE00 OWN CHRONIC SERIOUS HEALTH CONDITION
1. Did you check Box #4 on Page 2: Chronic Condition Requiring Treatment? !Yes !No* *If Employee does not have a chronic condition, pages 3 & 4 need not be completed.
2. Does the employee have an illness, impairment, or physical or mental condition that: (a) is chronic, ongoing and extends over a period of time; and (b) causes a period of incapacity or episodes of incapacity; and makes the employee unable to work as well as unable to perform other regular daily activities during such periods or episodes of incapacity? !Yes !No
3. If Yes to Q#2, please state the medical facts which support your conclusion. You may, instead, elect to provide the diagnosis of the condition. ________________________________________________________________________________________________________________________________________________________________
4. If Yes to Q#2: a. Approximately on what date did the employee00 condition begin? ________________________________ b. Approximately how long will the employee have the condition? __________________________________
5. If Yes to Q#2: a. Approximately how long is each period or episode of incapacity likely to last (i.e., 1 hour, half a day, 24 hours, etc.)? ________________________________________________________________________________ b. Approximately how frequently will the employee have an period or episode of incapacity (i.e. weekly, monthly, semi-monthly, bi-monthly, etc.)? _________________________________________________________ Please note that you must give an estimate for #5a and #5b. If you provide 00nknown00as an answer to either question, this certification will be incomplete, we will not be able to process the employee00 request for leave, and the employee will be required to obtain the information from you or run the risk of having his/her leave request denied. c. Is a period or episode of incapacity more likely to occur on any particular day of the week or time of day than others? !Yes !No If Yes to Q#5c, what day(s) of the week or time(s) of day are they more likely to occur and explain why a period or episode of incapacity is more likely to occur on such day(s) or time(s). ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. If Yes to Q#2: a. Please explain why it is 00edically necessary00for the employee to be absent from work because of this condition and why being absent from work is the 00est way to accommodate the employee00 condition.00___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ b. Please list all of the job duties the employee will be unable to perform during a period or episode of incapacity and explain why the employee will be unable to perform them. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ c. During a period or episode of incapacity, will the employee be unable to work at all doing any job (whether with us, for another employer, or in his/her own business)? !Yes !No If No, please explain why the employee will not be able to work for us but would be able to work for someone else or in his/her own business. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7. If Yes to Q#2, will the employee be required to call or be seen by any health care provider for evaluation or treatment each time s/he has a period or episode of incapacity? !Yes !No If No, please explain why the employee will not be required to consult with or be seen by a health care provider each time. That is, if the employee is so incapacitated that s/he cannot work or engage in other normal daily activities, why would it not be necessary for the employee to seek medical evaluation or treatment for that particular episode of incapacity? Please keep in mind that 00ncapacity00means that an employee is unable to work and is unable to perform normal daily activities. If the employee can perform normal daily activities at home, s/he is not incapacitated under this definition. If the employee is simply to stay at home and rest (except for doctor00 appointments and brief necessary trips to obtain medication) please so specify. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8. If Yes to Q#2, does the employee00 condition require periodic visits for treatment by a health care provider? !Yes !No
9. If Yes to Q#8, please answer the following: a. On what date was the employee last treated by you for this condition? ____________________________ b. Please list all other dates during the past 12 months on which the employee was treated by you for this condition: ________________________________________________________________________________________ c. Will the employee need treatment for this condition in the future? !Yes !No d. If Yes to Q#9c, please list the dates of all appointments for future treatment that are already scheduled. (if none, specify 00one00. _______________________________________________________________________________ e. If future treatment is needed, but appointments are not yet scheduled: 1) Provide an estimate of the probable number of treatments that the employee will need between now and June 30, the end of our fiscal year, for this condition: ____________________________________________________________________________________ 2) Provide an estimate of how frequently (i.e. weekly, monthly, or other interval) will these appointments for treatments be needed: ___________________________________________________ Please note that you must give an estimate to (1) and (2) above. If you provide 00nknown00 as an answer to either item, this certification will be incomplete, we will not be able to process the employee00 request for leave, and the employee will be required to obtain the information from you or run the risk of having his/her leave request denied.
10. Have you recommended or will you be recommending to the employee that s/he be evaluated or treated by any other health care provider for this condition? !Yes !No
If Yes, approximately how soon is the employee to see the other health care provider?____________________________
If Yes, please provide the other health care provider00 contact information: Name____________________________________________________________________________________________ Type of Practice ___________________________________________________________________________________ Name of Group ____________________________________________________________________________________ Address__________________________________________________________________________________________ Phone________________________________________ FAX_______________________________________________
*********************************************************************************************************************************** The undersigned hereby certifies that the above information is true and accurate. Signature of Health Care Provider
Type of Practice / Name of Group
Printed Name
Address
Date completed Phone Fax Page of 4

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