"Employee-To-Employee Leave Donation Request to Appeal Packet" - Maryland

Employee-To-Employee Leave Donation Request to Appeal Packet is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

Form Details:

  • Released on April 1, 2018;
  • The latest edition currently provided by the Maryland Department of Budget and Management;
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Download "Employee-To-Employee Leave Donation Request to Appeal Packet" - Maryland

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STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
REQUEST TO APPEAL FORM - FOR DENIAL OF LEAVE
(ALL FIELDS ARE REQUIRED)
NAME:
DATE:
HOME ADDRESS:
______
JOB TITLE AND SUMMARY OF DUTIES:
AGENCY NAME:
LAST DAY WORKED:
REQUEST IS FOR: EMPLOYEE
;
OR FAMILY MEMBER
My request for Employee-to-Employee leave should be reconsidered because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In addition to submitting your appeal, please have your treating physician(s) fax or email any
additional medical records that support your Employee-to-Employee Leave Appeal.
The
medical documentation should address only the period of time you are appealing. It must
include detailed information that explains the severity and duration of your (or your family
member’s) medical condition(s).
Please refer to the State Employee-to-Employee Leave
Donation Program – Medical Documentation sheet you received with your denial letter for
examples of the types of documentation that should be provided. The appeal and the records
may be emailed or faxed. Please follow the instructions in your denial letter.
MS 406-EE
Rev. 4/2018
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
REQUEST TO APPEAL FORM - FOR DENIAL OF LEAVE
(ALL FIELDS ARE REQUIRED)
NAME:
DATE:
HOME ADDRESS:
______
JOB TITLE AND SUMMARY OF DUTIES:
AGENCY NAME:
LAST DAY WORKED:
REQUEST IS FOR: EMPLOYEE
;
OR FAMILY MEMBER
My request for Employee-to-Employee leave should be reconsidered because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In addition to submitting your appeal, please have your treating physician(s) fax or email any
additional medical records that support your Employee-to-Employee Leave Appeal.
The
medical documentation should address only the period of time you are appealing. It must
include detailed information that explains the severity and duration of your (or your family
member’s) medical condition(s).
Please refer to the State Employee-to-Employee Leave
Donation Program – Medical Documentation sheet you received with your denial letter for
examples of the types of documentation that should be provided. The appeal and the records
may be emailed or faxed. Please follow the instructions in your denial letter.
MS 406-EE
Rev. 4/2018
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
AUTHORIZATION FORM FOR REVIEW OF RELEASED RECORDS AND INFORMATION
A. Identification: This document authorizes the use and/or disclosure of confidential protected health information
about the following person; this document is not used to request additional medical records or information
on the patient’s behalf.
Employee’s Name: _______________________________________ Date of Birth: _________________
Patient’s Name
: ____________________________ Date of Birth: __________________
(if not the employee)
B. Directions for Release:
I authorize the individual or company identified below in Section B.1b to release and/or use protected health
information pertaining to the individual listed in Section A to the individual(s) identified in Section B.1a.
B.1a.
I authorize the disclosure of information to:
o My Appointing Authority or Designee
o State of Maryland Employee-To-Employee Leave Donation Program
B.1b.
I authorize the release of information from:
o (Specify Health Care Provider) _______________________________________________________
o State Medical Director
B.2.
Information to be released: I authorize the disclosure and/or use of any information from my
medical records relating to the condition(s) for which I am seeking leave.
B.3.
Purposes: I authorize the disclosure and/or use for the following reason(s):
(a) to determine my eligibility for leave from the State of Maryland Employee-To-Employee
Leave Donation Program
B.4.
I am asking that you NOT provide any genetic information when responding to this request for medical
information. Genetic information, as defined by the Genetic Information Nondiscrimination Act of 2008,
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.
C. Right to Revoke: I understand that I may revoke this authorization at any time except to the extent that action
has already been taken in reliance upon it. This authorization will expire one year after the date it is signed. To
revoke the authorization, I must contact, in writing: Jennifer Hine, Director, Personnel Services, Department of
Budget and Management, 301 W. Preston Street, Room 705, Baltimore, MD 21201 or via Fax at 410-333-5440.
D. Authorization and Signature: I authorize the review of my confidential protected health information, as
described in my directions in Section B. I understand that this authorization is voluntary, the information to be
disclosed is protected by law and the disclosure will conform with my directions. The information that is used
and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is
covered by Maryland law which prohibits redisclosure or other laws limiting the use and/or disclosure of my
confidential protected health information.
I have read the contents of this authorization and I confirm that the contents are consistent with my directions.
I understand that by signing this form, I am authorizing the review and/or disclosure of my confidential
protected health information for determining my eligibility for leave.
________________________________
________________________________
___________________
Employee Signature
Patient Signature
Date
(if not employee)
(Rev. 4/2018)
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
MEDICAL DOCUMENTATION*
In most situations, your leave request will be evaluated without benefit of a
personal examination. Please have your health care provider(s) submit appropriate
medical documentation to support your request. The best thing to submit for a
favorable consideration is medical documentation that addresses ONLY the
period of time for which the leave is requested.
Listed below are examples of the type of medical documentation that should be
submitted, if applicable:
1) Office Visit Notes
2) Hospital Records (Operative Report & Discharge Summary)
3) Physical & Diagnostic Findings
4) Physician’s Statement Of Current Disability, Symptoms And Physical
Limitations (to explain why you cannot perform your job duties) and
Prognosis
5) Laboratory Reports (EEG, Myelogram, Angiography, Cat Scan, Etc.)
6) Reports Of X-Rays As Read By Examining Physician
7) Physical Therapy Notes
8) Reports from Specialists
9) Date and proof of surgery or other Procedure
10) For Pregnancy Cases, Expected Due Date and Actual Delivery Date,
Type of Delivery and Copy of Antepartum Record; a birth certificate is
not medical proof for birth.
*You must also provide sufficient medical documents to allow your request to be
reviewed appropriately if your request is to care for a family member.
Rev. 2/2018
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