Form HFLL-1 "Optional Form for Certification of a Serious Health Condition by a Health Care Provider" - Hawaii

What Is Form HFLL-1?

This is a legal form that was released by the Hawaii Department of Labor & Industrial Relations - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the Hawaii Department of Labor & Industrial Relations;
  • 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 HFLL-1 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Labor & Industrial Relations.

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Download Form HFLL-1 "Optional Form for Certification of a Serious Health Condition by a Health Care Provider" - Hawaii

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STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION
Princess Keelikolani Building, 830 Punchbowl
Street, Room 340, Honolulu, Hawaii 96813
-1 HAWAII FAMILY LEAVE
INSTRUCTION SHEET FOR HFLL
CERTIFICATION OF SERIOUS HEALTH CONDITION
Instructions
Please completely fill out the HFLL-1 HAWAII FAMILY LEAVE CERTIFICATION OF SERIOUS HEALTH CONDITION.
Please remember to sign and date the form before submitting it.
This is an optional form to be completed by the health care provider and returned to your employer.
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
Print Form
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION
Princess Keelikolani Building, 830 Punchbowl
Street, Room 340, Honolulu, Hawaii 96813
-1 HAWAII FAMILY LEAVE
INSTRUCTION SHEET FOR HFLL
CERTIFICATION OF SERIOUS HEALTH CONDITION
Instructions
Please completely fill out the HFLL-1 HAWAII FAMILY LEAVE CERTIFICATION OF SERIOUS HEALTH CONDITION.
Please remember to sign and date the form before submitting it.
This is an optional form to be completed by the health care provider and returned to your employer.
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION
Princess Keelikolani Building, 830 Punchbowl
Street, Room 340, Honolulu, Hawaii 96813
HFLL-1 HAWAII FAMILY LEAVE CERTIFICATION OF SERIOUS HEALTH
CONDITION
Under Chapter 398, Hawaii Revised Statutes, an employee is entitled to family leave to care for a child, parent, spouse or
reciprocal beneficiary with a serious health condition. This optional form may be used by employees to satisfy a
requirement to furnish a medical certification (when requested) from a health care provider. The form, to be filled out and
signed by the Health Care Provider of the patient with a serious health condition, should be returned to the employee to
submit to their employer to certify the serious health condition.
1. Employee's Name
2. Patient's Name
3. The last 2 pages describe what is meant by a "serious health condition" under the Hawaii Family Leave Law. Does the patient's
1
condition
qualify under any of the categories described? If so, please check the applicable category.
(1)
(2)
(3)
(4)
(5)
None of the above
(6), or
4. Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the
criteria for one of these categories:
5.a. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration
2
of the patient's present
if different):
incapacity,
b.
Will it be necessary for the employee to work only intermittently or on a less than full schedule as a result of the condition
(including for treatment described in Item 6 below)?
If yes, give the probable duration:
2
c.
If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated
and the
2
:
likely duration and frequency of episodes of incapacity
1
Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking
leave under the Hawaii Family Leave Law.
2
"Incapacity," for purposes of Hawaii Family Leave Law, is defined to mean inability to work, attend school or perform other
regular daily activities due to the serious health condition, treatment, or recovery.
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
HFLL-1 HAWAII FAMILY LEAVE CERTIFICATION OF SERIOUS HEALTH CONDITION
Page 2 of 4
6.a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments.
If the patient will be absent from work or other daily activities because of treatment on an intermittent or
basis, also
part-time
provide an estimate of the probable number of and interval between such treatments, actual or estimated dates of treatment if
known, and period required for recovery if any:
b.
If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature
of the treatments:
c.
If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such
regimen (e.g., prescription drugs, physical therapy requiring special equipment):
7.
The relationship of the patient with a serious health condition to the employee is:
Reciprocal beneficiary
Spouse
Parent (including biological parent, foster parent, adoptive parent, parent-in-law, stepparent, legal guardian, biological or
adoptive grandparent, or biological or adoptive grandparent-in-law)
Child (including a biological, adopted, or foster son or daughter; a stepchild; or a legal ward of the employee)
8.a. If leave is required to care for a child, parent, spouse or reciprocal beneficiary of the employee with a serious health condition,
does the patient require assistance for basic medical or personal needs, safety, or transportation?
b.
If no, would the employee's presence to provide psychological comfort be beneficial to the patient or assist in the patient's
recovery?
c.
If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need:
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
HFLL-1 HAWAII FAMILY LEAVE CERTIFICATION OF SERIOUS HEALTH CONDITION
Page 3 of 4
Signature of Health Care Provider
Type of Practice
Print Name
Title
Address
Telephone Number
Date
( )
To be completed by the employee requesting family leave to care for a family member:
State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be
taken intermittently, or if it will be necessary for you to work less than a full schedule:
____________________________________________________
_______________________
Employee Signature
Date
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
HFLL-1 HAWAII FAMILY LEAVE CERTIFICATION OF SERIOUS HEALTH CONDITION
Page 4 of 4
A "Serious Health Condition" means a physical or mental condition that warrants the participation of the employee to
provide care during the period of treatment of supervision by a health care provider and involves one of the following:
1. Hospital Care
Inpatient care
sidential medical care facility, including any period of
(i.e., an overnight stay) in a hospital, hospice, or re
2
incapacity
or subsequent treatment in connection with or consequent to such inpatient care.
2. Absence Plus Treatment
2
(a) A period of incapacity
of more than three (3) consecutive calendar days (including any subsequent treatment or
2
period of incapacity
relating to the same condition), that also involves:
3
(1) Treatment
two (2) or more times by a health care provider, by a nurse or physician's assistant under direct
supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under
orders of, or on referral by, a health care provider; or
(2) Treatment by a health care provider on at least one (1) occasion which results in a regimen of continuing
4
treatment
under the supervision of the health care provider.
3. Pregnancy
2
Any period of incapacity
due to pregnancy or prenatal care.
4. Chronic Conditions Requiring Treatments
A chronic condition which:
(1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under
direct supervision of a health care provider;
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
2
(3) May cause episodic rather than a continuing period of incapacity
(e.g., asthma, diabetes, epilepsy, etc.).
5. Permanent/Long-term Conditions Requiring Supervision
2
which is permanent or long-term due to a condition for which treatment may not be effective.
incapacity
A period of
under the continuing supervision of, but need not be receiving active
The employee or family member must be
treatment by, a health care provider. Examples include Alzheimer's, a severe stroke, or the terminal stages of a
disease.
6. Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery) by a health care provider or by
a provider of health care services under orders of, or on referral by, a health care provider, either for restorative
2
surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity
of more than
three (3) consecutive calendar days in the absence of medical intervention or treatment, such as cancer
(chemotherapy, radiation, etc.), severe arthritis (physical therapy), and kidney disease (dialysis).
__________________________________________________________________________________________________
2
"Incapacity," for purposes of Hawaii Family Leave Law, is defined to mean inability to work, attend school or perform other
regular daily activities due to the serious health condition, treatment, or recovery.
3
Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition.
Treatment does not include routine physical examinations, eye examinations, or dental examinations.
4
A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or
therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include
the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed
-rest, drinking fluids, exercise,
and other similar activities that can be initiated without a visit to a health care provider.
Visit our Website at www.labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 1/13)
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