Form MS 408 State Employees Leave Bank Request Form - Maryland

Form MS408 is a Maryland Department of Budget and Management form also known as the "State Employees Leave Bank Request Form". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download a PDF version of the Form MS408 down below or find it on Maryland Department of Budget and Management Forms website.

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EMPLOYEE INSTRUCTIONS FOR
SUBMITTING A LEAVE BANK REQUEST
This packet contains information and all forms REQUIRED to request leave from the Leave
Bank. Please use the checklist below to ensure ALL required forms are submitted:
Fact Sheet for the State Employees’ Leave Bank – Contains general information
about joining and applying for leave from the Leave Bank. Please review.
State Employees’ Leave Bank Request Form (MS-408) – Please complete Employee
Section and submit to your Agency Leave Bank Coordinator in your HR Office.
State Employees’ Leave Bank Medical Certification Form (MS-402) – Please have
your treating physician(s) complete ALL questions and submit to your Agency Leave
Bank Coordinator with packet. If applicable, proof of surgery or birth MUST be
provided. For birth of a child, the type of delivery must be noted on the medical form.
Authorization Form for Review of Released Records & Information (HIPAA
Form) – Please complete and submit to your Agency Leave Bank Coordinator with
packet.
Leave Bank – Medical Leave Documentation – See and review explanation below:
You must submit ALL of the above forms to your Agency’s Leave Bank Coordinator.
Your Agency will submit the Leave Bank Request to DBM for review and consideration.
A determination will be issued within 30 days of receiving all required forms and any
related documents. Failure to provide a fully completed and accurate packet may delay
the review process.
MEDICAL RECORDS/DOCUMENTATION
Medical records that address and support your work absence are the best documentation to
provide for favorable consideration of your request. For example, if you need leave to
cover your absence from January 1 to January 15, ask your treating physician(s) to submit
actual medical records/documentation that address the period from January 1 to January
15. It is not necessary for your physician to write any additional notes or letters.
See the attached list of acceptable Medical Documentation.
LB Instructions Form
Rev. 4/2018
EMPLOYEE INSTRUCTIONS FOR
SUBMITTING A LEAVE BANK REQUEST
This packet contains information and all forms REQUIRED to request leave from the Leave
Bank. Please use the checklist below to ensure ALL required forms are submitted:
Fact Sheet for the State Employees’ Leave Bank – Contains general information
about joining and applying for leave from the Leave Bank. Please review.
State Employees’ Leave Bank Request Form (MS-408) – Please complete Employee
Section and submit to your Agency Leave Bank Coordinator in your HR Office.
State Employees’ Leave Bank Medical Certification Form (MS-402) – Please have
your treating physician(s) complete ALL questions and submit to your Agency Leave
Bank Coordinator with packet. If applicable, proof of surgery or birth MUST be
provided. For birth of a child, the type of delivery must be noted on the medical form.
Authorization Form for Review of Released Records & Information (HIPAA
Form) – Please complete and submit to your Agency Leave Bank Coordinator with
packet.
Leave Bank – Medical Leave Documentation – See and review explanation below:
You must submit ALL of the above forms to your Agency’s Leave Bank Coordinator.
Your Agency will submit the Leave Bank Request to DBM for review and consideration.
A determination will be issued within 30 days of receiving all required forms and any
related documents. Failure to provide a fully completed and accurate packet may delay
the review process.
MEDICAL RECORDS/DOCUMENTATION
Medical records that address and support your work absence are the best documentation to
provide for favorable consideration of your request. For example, if you need leave to
cover your absence from January 1 to January 15, ask your treating physician(s) to submit
actual medical records/documentation that address the period from January 1 to January
15. It is not necessary for your physician to write any additional notes or letters.
See the attached list of acceptable Medical Documentation.
LB Instructions Form
Rev. 4/2018
FACT SHEET FOR THE STATE EMPLOYEE’S LEAVE BANK
Employees who join the Leave Bank for the very first time must wait 90 days before requesting leave.
Membership is for a two-year period and may be renewed during Open Enrollment by donating an
additional eight hours of leave. It is the responsibility of each employee to verify that the Leave Bank
membership has been received and processed by the Agency Human Resources (HR) Office.
Please
check with your HR Office if you have questions about your Leave Bank eligibility or membership.
To qualify for leave from the Leave Bank, an employee:
 must be an active member of the Leave Bank;
 must have exhausted all forms of annual, sick, personal and compensatory leave;
 must qualify for the use of sick leave under the requirements of the employee’s personnel
system;
 must have received a satisfactory performance rating;
 must have a serious and prolonged medical condition;
 must provide sufficient medical documentation to substantiate absence for the time period
covered by the Leave Bank request;
 must be able, in all likelihood, to return to work;
 must have received less than 2,080 hours of leave from the Leave Bank and/or the Employee-
to-Employee Leave Donation Programs;
 must not have a record of sick leave abuse (i.e., must not have been on a one-day sick slip
restriction within the past two years);
 must not have been disciplined within the past year; and
 must not have used more than 16 continuous months of leave from the Leave Bank and all
other forms of paid leave.
To request leave from the Leave Bank, members must complete and submit a State Employees’ Leave
Bank Request Packet and provide medical records that address the absence for which Leave Bank is
requested. Leave Bank forms are available from your HR Office or on the Department of Budget and
Management (DBM) website at www.dbm.maryland.gov. Please submit ALL completed forms and
medical documentation to your HR Office. The HR Office will review and send the Leave Bank request
to DBM for consideration. DBM will issue a determination within 30 days of receiving ALL required
forms and any related documents.
If an employee exhausts accrued leave before DBM makes its determination, the employee shall be
granted leave until a decision is rendered. If an employee is automatically granted leave and the request
is subsequently denied, any leave used must be recovered. The employee shall reimburse the State at a
minimum rate of one half of all sick leave earned. At the employee’s discretion, additional sick leave
and any accrued annual, personal or compensatory leave may be applied to the reimbursement or the
employee may elect to make cash payments.
Approval to use leave from the Leave Bank is discretionary. Denial may be based on any reason that
is consistently applied and is not illegal or unconstitutional.
LB Fact Sheet
Rev. 6/2017
STATE EMPLOYEES LEAVE BANK REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
(Please TYPE or PRINT)
Name*:
SS#*:
Hire Date:
* Your full Name and Social Security Number is required to help verify your identity and process your Request. Failure to provide it may result in delays
and/or rejection of your request. This information is kept confidential in accordance with Federal and State laws and regulations.
State Hire Date:
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Request Type:
New
Extension
Updated
Full Agency Name:
Signature:
Date:
TO BE COMPLETED BY AGENCY HR/LEAVE BANK COORDINATOR
Leave Bank Coordinator:
Email:
Phone #:
Fax #:
Last Date Employee Worked:
Leave Bank Membership Expiration Date**:
Hours Needed: __________ Hrs
Dates to Cover: From
Through
Can agency accommodate a modified duty assignment? No
Yes
Is employee on FMLA leave? No
Yes
If Yes, provide end date of current FMLA:
Has employee been on one-day sick slip restriction within the last two years? No
Yes
If Yes, provide effective date of restriction:
Has employee been disciplined within the last year? No
Yes
If Yes, provide effective date of disciplinary action:
Employee’s last performance evaluation rating was:
Satisfactory or Above
Less than Satisfactory
Is this absence due to an on-the-job injury? No
Yes
If Yes, Contact DBM Leave Bank Program Manager
Has the employee been seen by the State Medical Director? No
Yes
If Yes, Provide copy of Medical Report
Has the employee applied for Disability Retirement? No
Yes
If Yes, Provide copy of signed SRA 129
Leave Bank Coordinator’s Signature:
Date:
**COPY OF MOST CURRENT LEAVE BANK MEMBERSHIP FORM IS REQUIRED
COMPLETED BY APPOINTING AUTHORITY OR DESIGNEE
This employee has exhausted all forms of annual, sick, personal and compensatory time because of a serious and
prolonged medical condition. The employee has been a member of the Leave Bank for at least 90 days or has been
granted an exemption by the Secretary of Budget and Management. Approval will not cause the employee to exceed
2,080 hours of leave from the Leave Bank and Employee-to-Employee Leave Donation Programs during his/her entire
State employment. Approval will not cause the employee to exceed 16 months of continuous leave, when combined
with all other forms of paid leave. As the appointing authority for this employee, I have reviewed the employee’s
records and I certify that this request meets all of the criteria specified in this Section.
______________________________________________________________
______________________________________
Signature of Appointing Authority or Designee
Date
MS 408
(Rev. 4/2018)
STATE EMPLOYEES’ LEAVE BANK REQUEST
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY EMPLOYEE’S TREATING PHYSICIAN
PATIENT’S NAME: _________________________________________________________________
DIAGNOSIS(ES):
_________________________________________________________________
____________________________________________________________________________________
ICD 10 CODE(S):
_____________
_____________
_____________
_____________
SUMMARY OF TREATMENT(S) & PROCEDURE(S): __________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
START DATE OF CURRENT INCAPACITY: __________________________________________
SURGERY DATE (IF APPLICABLE): ________________________________________________
HOSPITALIZATION DATE(S) (IF APPLICABLE): FROM: ____________ TO: ____________
CAN EMPLOYEE WORK IN A MODIFIED CAPACITY?
YES_________
NO_________
IF YES, PROVIDE RESTRICTIONS FOR MODIFIED DUTY:
__________________________________________________________________________
__________________________________________________________________________
DATE EMPLOYEE IS LIKELY TO RETURN TO:
MODIFIED DUTY: __________________________
FULL DUTY: _______________________
____________________________________________
____________________________________
PHYSICIAN’S NAME (PRINTED)
PHYSICIAN’S PHONE NUMBER
____________________________________________
____________________________________
PHYSICIAN’S SIGNATURE
DATE FORM COMPLETED
(PLEASE ATTACH MEDICAL VERIFICATION OF SURGERY OR BIRTH –
TYPE OF BIRTH IS REQUIRED)
Failure to provide sufficient medical documentation may delay the processing of this request. This
information shall be treated as a confidential medical record; it shall not be placed in the employee’s
personnel file. Only those individuals with a need to know this information will be given access to it. An
employee who fails to appropriately safeguard the confidentiality of this information will be subject to
disciplinary action, including termination from State Service.
MS 402-LB
(Rev. 4/2018)
STATE EMPLOYEES’ LEAVE BANK 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 is not used to request medical records or information on the employee’s
behalf.
Employee’s Name: ______________________________________
Date of Birth: ___________________
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 State Medical Director
o State Employees’ Leave Bank 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 Employees’ Leave Bank 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.
________________________________
___________________
Employee Signature
Date
(Rev. 4/2018)
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