"Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act)" - Delaware

Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act) is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

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State of Delaware
Department of Human Resources
Certification of Health Care Provider for Family Member's Serious Health Condition
(Family and Medical Leave Act)
Authority: The Family and Medical Leave Act
Policy #: To be assigned
of 1993, as amended February 25, 2015; M.R. 5.7
Effective Date: November 20, 2019
Supersedes: January 2009
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA protections because of a need for leave to care for a covered family
member with a serious health condition to submit a medical certification issued by the health care provider of the
covered family member. Please complete Section I before giving this form to your employee. Your response is
voluntary. While you are not required to use this form, 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’ family
members, 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), if the Americans with Disabilities Act applies,
and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Employer name and contact:
Agency name and address:
______________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family
member or his/her 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 to care for a covered family
member with a 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. (29 C.F.R. § 825.313) Your employer must give
you at least 15 calendar days to return this form to your employer. (29 C.F.R. § 825.305)
Your name:
Last
First
Middle
Name of family member for whom you will provide care:
First
Middle
Last
Relationship of family member to you:
If family member is your son or daughter, date of birth:
Describe care you will provide to your family member and estimate leave needed to provide care:
__________________________________________________
_____________________________________
Employee Signature
Date
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State of Delaware
Department of Human Resources
Certification of Health Care Provider for Family Member's Serious Health Condition
(Family and Medical Leave Act)
Authority: The Family and Medical Leave Act
Policy #: To be assigned
of 1993, as amended February 25, 2015; M.R. 5.7
Effective Date: November 20, 2019
Supersedes: January 2009
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA protections because of a need for leave to care for a covered family
member with a serious health condition to submit a medical certification issued by the health care provider of the
covered family member. Please complete Section I before giving this form to your employee. Your response is
voluntary. While you are not required to use this form, 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’ family
members, 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), if the Americans with Disabilities Act applies,
and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Employer name and contact:
Agency name and address:
______________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family
member or his/her 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 to care for a covered family
member with a 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. (29 C.F.R. § 825.313) Your employer must give
you at least 15 calendar days to return this form to your employer. (29 C.F.R. § 825.305)
Your name:
Last
First
Middle
Name of family member for whom you will provide care:
First
Middle
Last
Relationship of family member to you:
If family member is your son or daughter, date of birth:
Describe care you will provide to your family member and estimate leave needed to provide care:
__________________________________________________
_____________________________________
Employee Signature
Date
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Policy #: To be assigned.
Certification of Health Care Provider for Family Member’s Serious
Rev. Date:
Health Condition (Family and Medical Leave Act)
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under
the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. Several questions
seek a response as to the 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 patient needs leave. Do not provide information
about genetic tests, as defined in 29 C.F.R. § 1635.3(f) or genetic services, as defined in 29 C.F.R. § 1635.3(e).
Page 4 provides space for additional information, should you need it. Please be sure to sign the form on the last
page.
Provider’s name and business address:
Type of practice / Medical specialty:
___________________________________
Telephone:
Fax:
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?
_____ No _____ Yes. If so, dates of admission:
Date(s) you treated the patient for condition:
Was medication, other than over-the-counter medication, prescribed? _____ No _____ Yes.
Will the patient need to have treatment visits at least twice per year due to the condition? ___ No ___ Yes.
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
_____ No _____ Yes. If so, state the nature of such treatments and expected duration of treatment:
2. Is the medical condition pregnancy? _____No _____Yes. If so, expected delivery date:
3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of
specialized equipment):
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Certification of Health Care Provider for Family Member’s Serious
Policy #: To be assigned.
Health Condition (Family and Medical Leave Act)
Rev. Date:
PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s
need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional,
safety or transportation needs, or the provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment
and recovery? _____ No _____ Yes.
Estimate the beginning and ending dates for the period of incapacity:
During this time, will the patient need care? _____ No _____ Yes.
Explain the care needed by the patient and why such care is medically necessary:
5. Will the patient require follow-up treatments, including any time for recovery? _____ No _____ Yes.
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required
for each appointment, including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?
_____ No _____ Yes.
Estimate the hours the patient needs care on an intermittent basis, if any:
hour(s) per day;
days per week
from
through
Explain the care needed by the patient, and why such care is medically necessary:
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Certification of Health Care Provider for Family Member’s Serious
Policy #: To be assigned.
Health Condition (Family and Medical Leave Act)
Rev. Date:
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily
activities? _____ No _____ 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 six months (e.g., one
episode every three months lasting one to two days):
Frequency: ______ times per ______ week(s) ______ month(s)
Duration: ______ hours or ______ day(s) per episode
Does the patient need care during flare-ups? _____ No _____ Yes.
Explain the care needed by the patient, and why such care is medically necessary:
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
__________________________________________________
____________________________________________
Signature of Health Care Provider
Date
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Certification of Health Care Provider for Family Member’s Serious
Policy #: To be assigned.
Health Condition (Family and Medical Leave Act)
Rev. Date:
PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, in accordance with
29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for
respondents to complete this collection of information, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any
comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing
this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200
Constitution AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND
HOUR DIVISION; RETURN IT TO THE PATIENT.
Notification to Healthcare Providers
Title II of the Genetic Information Nondiscrimination Act (GINA) “prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of employees or their family
members. In order 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 test, 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.”
Additional Notification Relating to Pregnancy and Employment:
Employees, as defined in SB 212, shall be free from discrimination in relation to pregnancy, childbirth,
and related conditions, including the right to reasonable accommodation to known limitations related to
pregnancy, childbirth and related conditions pursuant to Title 19 of the Delaware Code, Chapter 7. See 19
Delaware Code Section 711(a)(3).
For Agency Use Only
Date Issued to Employee:
Date Returned by Employee:
Date Approved:
Date Denied:
Date Returned to Employee for
additional information:
Reviewed by:
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