"Fmla Certification of Health Care Provider for Employee's" - Nevada

Fmla Certification of Health Care Provider for Employee's is a legal document that was released by the Nevada Department of Administration - a government authority operating within Nevada.

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STATE OF NEVADA
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH
CONDITION (FAMILY MEDICAL LEAVE ACT)
SECTION I: For Completion by the AGENCY
INSTRUCTIONS to the AGENCY: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee
seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the
employee’s health care provider. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29
C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or
medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel
files and in accordance with 29 C.F.R. § 1630.14(c)(1).
Agency:
Agency Contact:
Employee’s job title:
Employee’s essential job functions/job description is attached.
Yes
No
Regular work schedule:
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your
own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections.
29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA
request. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name:
______________________________________________________________________________________________________________
(First)
(Middle)
(Last)
(Employee ID #)
SECTION III: For Completion by HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely,
all applicable parts. Several questions seek a response as to 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 employee is seeking leave. Please be sure to sign the form on the last page.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To
comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.
‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.
Provider’s name:
Business address:
Type of practice/Medical specialty:
Telephone number:
Fax number:
Page 1 of 3
STATE OF NEVADA
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH
CONDITION (FAMILY MEDICAL LEAVE ACT)
SECTION I: For Completion by the AGENCY
INSTRUCTIONS to the AGENCY: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee
seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the
employee’s health care provider. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29
C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or
medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel
files and in accordance with 29 C.F.R. § 1630.14(c)(1).
Agency:
Agency Contact:
Employee’s job title:
Employee’s essential job functions/job description is attached.
Yes
No
Regular work schedule:
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your
own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections.
29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA
request. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name:
______________________________________________________________________________________________________________
(First)
(Middle)
(Last)
(Employee ID #)
SECTION III: For Completion by HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely,
all applicable parts. Several questions seek a response as to 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 employee is seeking leave. Please be sure to sign the form on the last page.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To
comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.
‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.
Provider’s name:
Business address:
Type of practice/Medical specialty:
Telephone number:
Fax number:
Page 1 of 3
Part A — MEDICAL FACTS
(1) Approximate date condition commenced: ________________________________________________________________________
Probable duration of condition: ___________________________________________________________________________ _____
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes
No
If so, dates of admission: ___________________________________________________________________________________
Date(s) you treated the patient for condition: ______________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition?
Yes
No
Was medication, other than over-the-counter medication, prescribed?
Yes
No
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
Yes
No
If so, state the nature of such treatments and expected duration of treatment: ___________________________________________
________________________________________________________________________________________________________
(2) Is the medical condition pregnancy?
Yes
No
If so, expected delivery date:
(3) Use the information provided by the employer (see Section I and attached) to answer this question. If the employer fails to provide a
list of the employee’s essential job functions or a job description, answer these questions based upon the employee’s own description of
his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition?
Yes
No
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):
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Page 2 of 3
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?
Yes
No
If so, estimate the beginning and ending dates for the period of incapacity:
(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?
Yes
No
If so, are the treatments or the reduced number of hours of work medically necessary?
Yes
No
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?
Yes
No
Is it medically necessary for the employee to be absent from work during the flare-ups?
Yes
No
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
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________
_______________________________________
Signature of Health Care Provider
Date
NPD-83 1/11
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