Form CALHR755 "Certification of Health Care Provider for Family Member's Serious Health Condition" - California

What Is Form CALHR755?

This is a legal form that was released by the California Department of Human Resources - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the California Department of Human Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CALHR755 by clicking the link below or browse more documents and templates provided by the California Department of Human Resources.

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Download Form CALHR755 "Certification of Health Care Provider for Family Member's Serious Health Condition" - California

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Certification of Health Care Provider for Family
Member's Serious Health Condition
California Department of Human Resources
State of California
Print Form
Reset Form
FAMILY AND MEDICAL LEAVE ACT (FMLA)
AND CALIFORNIA FAMILY RIGHTS ACT (CFRA)
Part A. For Completion by the Employee
Instructions to the EMPLOYEE: Please Complete Part A before giving this form to your family member
or his/her health care provider. The law permits us to require that you submit a timely, complete, and
sufficient medical certification to support a request for leave to care for a covered family member with a
serious health condition. Your response is required to obtain or retain the benefit of FMLA/CFRA
protections. Failure to provide a complete and sufficient medical certification may result in a denial of
your leave request. You have 15 calendar days to return this form.
Employee Last Name
Employee First Name
Employee Middle Name
Telephone Number
Employee Classification
Employee Work Unit
Regular Work Schedule:
Days
Nights
Full Time
Part Time
Last Day Worked
9/80
4/10
Other:
1. Relation to employee:
child/child of domestic partner
child's date of birth:
spouse
parent
domestic partner
2. Name of family member for who you will provide care:
Last Name
Middle Name
First Name
3. Describe the care you will provide to your family member and estimate how much time you will need
to take to provide the care:
4. I certify that the information I have provided is true and correct.
Employee Signature
Date
Part B. For Completion by the Health Care Provider
INSTRUCTIONS for the HEALTH CARE PROVIDER: The employee listed above has requested leave
under FMLA/CFRA to care for your patient. Please answer fully and completely all applicable parts.
Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your
answers should be your best estimate based upon your medical knowledge, experience and
examination of the patient. Please be as specific as you can; terms such as "lifetime," "unknown" or
"indeterminate may not be sufficient to determine FLMA/CFRA coverage. Please do not disclose the
underlying diagnosis without the consent of your patient. Please limit responses to the condition
which the employee is seeking leave for the family member. Please be sure to sign and date the
form on page three.
CalHR 755
(rev 07/2016)
Page of
Certification of Health Care Provider for Family
Member's Serious Health Condition
California Department of Human Resources
State of California
Print Form
Reset Form
FAMILY AND MEDICAL LEAVE ACT (FMLA)
AND CALIFORNIA FAMILY RIGHTS ACT (CFRA)
Part A. For Completion by the Employee
Instructions to the EMPLOYEE: Please Complete Part A before giving this form to your family member
or his/her health care provider. The law permits us to require that you submit a timely, complete, and
sufficient medical certification to support a request for leave to care for a covered family member with a
serious health condition. Your response is required to obtain or retain the benefit of FMLA/CFRA
protections. Failure to provide a complete and sufficient medical certification may result in a denial of
your leave request. You have 15 calendar days to return this form.
Employee Last Name
Employee First Name
Employee Middle Name
Telephone Number
Employee Classification
Employee Work Unit
Regular Work Schedule:
Days
Nights
Full Time
Part Time
Last Day Worked
9/80
4/10
Other:
1. Relation to employee:
child/child of domestic partner
child's date of birth:
spouse
parent
domestic partner
2. Name of family member for who you will provide care:
Last Name
Middle Name
First Name
3. Describe the care you will provide to your family member and estimate how much time you will need
to take to provide the care:
4. I certify that the information I have provided is true and correct.
Employee Signature
Date
Part B. For Completion by the Health Care Provider
INSTRUCTIONS for the HEALTH CARE PROVIDER: The employee listed above has requested leave
under FMLA/CFRA to care for your patient. Please answer fully and completely all applicable parts.
Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your
answers should be your best estimate based upon your medical knowledge, experience and
examination of the patient. Please be as specific as you can; terms such as "lifetime," "unknown" or
"indeterminate may not be sufficient to determine FLMA/CFRA coverage. Please do not disclose the
underlying diagnosis without the consent of your patient. Please limit responses to the condition
which the employee is seeking leave for the family member. Please be sure to sign and date the
form on page three.
CalHR 755
(rev 07/2016)
Page of
Employee Last Name
Employee First Name
Employee Middle Name
Provider Name (You may attach a business card in lieu of completing this section)
Business Address
City
State Zip Code
Type of Practice / Medical Specialty
Telephone
Fax
Part C. Medical Facts
1. Does the patient have a serious health condition that qualifies under the categories described on the
attached sheet?
If no, sign and date page three and return to patient.
Yes
No
2. If the patient has a serious health condition as defined in the attached sheet, please answer the
following:
Approximate Date Condition Commenced:
Probable Duration of Medical Condition or Need for Treatment:
3. Dates treated for condition:
4. Will the patient need to have treatment visits at least twice per year due to the condition?
Yes
No
5. Was medication (other than over-the-counter) prescribed?
Yes
No
6. Does the condition of the patient warrant the participation of the employee? (This may include
psychological comfort and or arranging for third party care for the family member)
Yes
No
Part D. Amount of Care Needed
When answering these questions, keep in mind the patient's need for care by the employee seeking
leave may include assistance for basic medical, hygiene, nutritional, safety, transportation needs, the
provision of physical or psychological care.
1. Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical
therapist)?
Yes
No
If yes, state the frequency and expected duration of such treatment(s):
2. 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?
Yes
No
If yes, estimate the period of incapacity. beginning date:
ending date:
3. Will the patient require follow-up treatment, including any recovery time?
Yes
No
If yes, estimate the schedule, if any, including dates of any scheduled appointments and the time
required for each appointment, including any recovery period.
CalHR 755
(rev 07/2016)
Page of
Employee Last Name
Employee First Name
Employee Middle Name
4. During this time, will the patient need care which the employee's presence would be beneficial?
Yes
No
If yes, explain the care needed by the patient and why such care is medically necessary
5. Please answer the following questions only if the employee is requesting intermittent leave or
a reduced work schedule.
Is it medically necessary for the employee to be off work on an intermittent basis or to work less
than the employee's normal work schedule in order to care for the serious health condition of the
family member?
Yes
No
If yes, please indicate the estimated number of doctor's visits, and/or estimated duration of medical
treatment(s):
hour(s) per day;
days per week from
through
6. Will the condition cause episodic flare-ups periodically preventing the patient from participating in
Yes
No
normal daily activities?
If 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 (i.e..e, 1 episode every 3 months lasting 1-2 days):
times per
week(s)
month(s)
Frequency:
Duration:
hours
day(s) per event
Yes
No
Does the patient need care during these flare-ups?
ADDITIONAL INFORMATION- Identify question number with any additional information
Please attach a separate sheet of paper if additional space is needed.
Signature below verifies that the information provided above is true and accurate.
Health Care Provider Signature
Date
Dear Health Care Provider,
Do NOT Provide the patient's diagnosis without the consent of the patient.
The employee has requested leave under the Federal and/or California family and medical leave
statutes for the purpose of caring for your patient (who is a parent, child, or spouse/domestic partner of
the employee).
Thank you for your assistance.
CalHR 755
(rev 07/2016)
Page of
Employee Last Name
Employee First Name
Employee Middle Name
Definition of a Serious Health Condition
Serious health condition is any illness, injury, impairment, physical or mental condition that involves:
1. Any period of incapacity or treatment in connection with or consequent to an overnight stay in a hospital, hospice,
or residential medical care facility; or
2. Continuing treatment by a health care provider for one or more of the following:
a. Any period of incapacity due to a chronic serious health condition that:
i. Requires periodic ( at least two visit per year) visits for treatment
ii. Continues over an extended period of time; and
iii. May cause episodic rather than a continuing period of incapacity (e.g., asthma,
diabetes, epilepsy, etc.)
3. Any period of incapacity which is long-term due to a condition for which treatment may not be effective
(e.g., Alzheimer's disease)
4. Any period of absence required to receive multiple treatments (including the period of recovery) either for
restorative surgery after an accident or other injury, or for a chronic condition.
A Serious Health Condition is Generally Not:
1. Allergies, stress, or substance abuse unless inpatient hospital care is provided, or the patient is incapacitated for
more than three calendar days and is under the continuing care of a health care provider, or the patient has a
serious long-term health condition; or
2. Voluntary treatment or surgery inpatient hospital care is required.
A Health Care Provider Is:
Department of Labor regulations for the Family and Medical Leave Act define a "health care provider" as a doctor of medicine
or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, or clinical
social worker, physicians assistant, who is authorized to practice by the State and performing within the scope of their
practice as defined by State law, or a Christian Science practitioner. A health care provider also is any provider from whom
the University or the employee's group health plan will accept certification of a serious health condition to substantiate a claim
for benefits.
Privacy Notice
This notice is provided pursuant to the Information Practices Act of 1977.
The California Department of Human Resources (CalHR), Personnel Management Division is requesting the information
specified on this form. The information collected will be by your department for purposes of determining your eligibility for
FMLA/CFRA benefits.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide the information
requested, there may be a delay in processing your request.
Department Privacy Policy
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977 and state policy. For
more information on how we care for your personal information, please read our Privacy Policy on CalHR's website
(calhr.ca.gov).
Access to Your Information
Information provided on this form will be maintained by the CalHR Personnel Management Division pursuant to State
Administrative Manual retention requirements. Individuals have the right of access to copies of this form on request. Send
requests to:
Personnel Management Division
Department of Human Resources
1515 S Street, Suite 500N
Sacramento, CA 95811
CalHR 755
(rev 07/2016)
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