Form FML2 "Certification of Healthcare Provider - Employee" - City and County of San Francisco, California

What Is Form FML2?

This is a legal form that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Department of Human Resources - City and County of San Francisco, California;
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FML2
CITY AND COUNTY OF SAN FRANCISCO
Employee
Certification of Health Care Provider under the
Family and Medical Leave Act (FMLA), California Family Rights Act (CFRA) And
Pregnancy Disability Leave (PDL)
Use This Form For an Employee’s Serious Health Condition
PLEASE GIVE THIS FORM TO YOUR HEALTH CARE PROVIDER
AFTER COMPLETING SECTION A
Section A: To Be Completed By the Employee
Employee’s Name: _______________________________________Classification: __________________________________
Department: ___________________________________________________________________________________________
Personnel Official’s Name: _________________________________ Telephone Number: ____________________________
Section B: Instructions to the Health Care Provider
Certification of Health Care Provider of a Serious Health Condition
(Family and Medical Leave Act (FMLA) of 1993, California Family Rights Act (CFRA)
and Pregnancy Disability Leave (PDL).)
Dear Health Care Provider:
The above-named employee has requested a leave of absence or intermittent leave for his/her health condition, which may
qualify as a protected leave under the FMLA, CFRA and/or PDL. This medical certification form will provide us with
information needed to determine if the employee is eligible for leave under the FMLA, CFRA and/or PDL. Sections C-G must
be completed by you and returned to the department by the employee or your office. In all cases, it is the employee’s
responsibility to ensure that sufficient medical certification is provided to the employer.
INSTRUCTIONS
The information sought on this form relates only to the condition for which the employee is taking leave. For the purposes of
this form, “incapacity” is defined as the inability to work, attend school, or perform other regular daily activities due to the
serious health condition itself, treatment of the serious health condition, or recovery from the condition. “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. 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 taking over-the-counter medications such
as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, or other similar activities that can be initiated
without a visit to a health care provider.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic
information of an individual or family member of the individual, except as specifically allowed by GINA. To comply with GINA,
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 individual's family member sought or received genetic services,
and genetic information of a fetus to be 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.
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
FML2
CITY AND COUNTY OF SAN FRANCISCO
Employee
Certification of Health Care Provider under the
Family and Medical Leave Act (FMLA), California Family Rights Act (CFRA) And
Pregnancy Disability Leave (PDL)
Use This Form For an Employee’s Serious Health Condition
PLEASE GIVE THIS FORM TO YOUR HEALTH CARE PROVIDER
AFTER COMPLETING SECTION A
Section A: To Be Completed By the Employee
Employee’s Name: _______________________________________Classification: __________________________________
Department: ___________________________________________________________________________________________
Personnel Official’s Name: _________________________________ Telephone Number: ____________________________
Section B: Instructions to the Health Care Provider
Certification of Health Care Provider of a Serious Health Condition
(Family and Medical Leave Act (FMLA) of 1993, California Family Rights Act (CFRA)
and Pregnancy Disability Leave (PDL).)
Dear Health Care Provider:
The above-named employee has requested a leave of absence or intermittent leave for his/her health condition, which may
qualify as a protected leave under the FMLA, CFRA and/or PDL. This medical certification form will provide us with
information needed to determine if the employee is eligible for leave under the FMLA, CFRA and/or PDL. Sections C-G must
be completed by you and returned to the department by the employee or your office. In all cases, it is the employee’s
responsibility to ensure that sufficient medical certification is provided to the employer.
INSTRUCTIONS
The information sought on this form relates only to the condition for which the employee is taking leave. For the purposes of
this form, “incapacity” is defined as the inability to work, attend school, or perform other regular daily activities due to the
serious health condition itself, treatment of the serious health condition, or recovery from the condition. “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. 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 taking over-the-counter medications such
as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, or other similar activities that can be initiated
without a visit to a health care provider.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic
information of an individual or family member of the individual, except as specifically allowed by GINA. To comply with GINA,
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 individual's family member sought or received genetic services,
and genetic information of a fetus to be 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.
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
Employee’s Name: ______________________________________
FML2
Employee
Page 2 of 4
Section C: Definition of a Serious Health Condition
The definitions below describe what is meant by a “serious health condition” under the FMLA and/or CFRA. Does the
patient’s condition(s) qualify under any of the categories described? If so, please check the appropriate category.
 CATEGORY 1: In-Patient Care
Any period of incapacity or treatment connected with inpatient care (i.e., an overnight stay) in a hospital, hospice,
or residential medical care facility, including any period of incapacity or subsequent treatment in connection with
or consequent to such inpatient care.
 CATEGORY 2: Absence Plus Treatment
A period of incapacity of more than three (3) consecutive full calendar days, and any subsequent treatment or
period of incapacity relating to the same condition, which also involves:
a) Treatment two (2) or more times, within 30 days of the first day of incapacity, by a health care provider, by a
nurse 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
b) Treatment by a health care provider on at least one (1) occasion, which results in a regimen of continuing
treatment under the supervision of the health care provider, e.g., prescribed medication.
 CATEGORY 3: Pregnancy or Prenatal Care
Any period of incapacity due to pregnancy, or for prenatal care. Expected delivery date: _____________________
 CATEGORY 4: Chronic Conditions
Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. A chronic
serious health condition is one which:
a) 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;
b) Continues over an extended period of time, including recurring episodes of a single underlying condition; and
c) May cause episodic rather than a continuing period of incapacity, e.g., asthma, diabetes, epilepsy, etc.
 CATEGORY 5: Permanent or Long-Term Conditions Requiring Supervision
A period of incapacity, which is permanent or long-term, due to a condition for which treatment may not be
effective. The employee or family member must be under the continuing supervision of, but need not be receiving
active treatment by, a health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages
of a disease.
 CATEGORY 6: Conditions Requiring Multiple Treatments
Any period of absence to receive multiple treatments, including any period of recovery therefrom, by a health care
provider or by a provider of health care services under orders of, or on referral by, a health care provider, for:
a) Restorative surgery after an accident or other injury; or
b) A condition that would likely result in a period of incapacity of more than three (3) consecutive, full calendar
days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe
arthritis (physical therapy), or kidney disease (dialysis).
 NO CATEGORY APPLIES
Continue To Next Page
DHR FML2 (Rev. 08/2017)
Employee’s Name: ______________________________________
FML2
Employee
Page 3 of 4
Section D: Supporting Medical Facts
Note: The health care provider is not to disclose the underlying diagnosis without the patient’s consent.
1. State the approximate date the condition began: ______________________________________________________
2. State the probable duration of the condition or need for treatment: ________________________________________
3. State the probable duration of the patient’s incapacity, if different from the duration of the condition:
_______________________________________________________________________________________________
____
Section E: Amount of Leave Requested
(Only Check and Complete the Section(s) That Apply)
 CONTINUOUS LEAVE
The employee will require CONTINUOUS LEAVE due to his/her serious health condition, including any time for
treatment and recovery.
Estimate the beginning and ending dates for the period of incapacity: From ____________ through ____________
INTERMITTENT LEAVE
It is medically necessary for the employee to take INTERMITTENT LEAVE because the employee’s serious health
condition causes episodic incapacity due to flare-ups or urgent care.
a. Estimate the frequency of flare-ups or the need for urgent care:
Frequency: __________ times per __________ week / month / year (circle one)
b. Estimate the duration of time the employee will be incapacitated by each occurrence/episode:
Duration: ________hours / days per incident (circle one)
Dates flare-ups or need for urgent care may occur: From ____________________ through __________________
TREATMENT OR APPOINTMENTS
It is medically necessary for the employee to attend follow- up TREATMENT or APPOINTMENTS because of the
employee’s serious health condition.
a. Estimate the schedule, including dates of any scheduled treatment or appointments and time required for each
appointment. Include recovery time.
Scheduled Treatment/Appointments: ________ times per week / month / year (circle one)
Duration: __________ hours / days per treatment/appointment (circle one)
Estimate dates, times, and length of scheduled appointments: __________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
b. Can treatment/appointments be scheduled during non-work hours?  Yes  No
Dates treatment/appointments can be scheduled: From: ____________________ through __________________
Continue To Next Page
DHR FML2 (Rev. 08/2017)
Employee’s Name: ______________________________________
FML2
Employee
Page 4 of 4
Section E: Amount of Leave Requested
\\\\
(Continued)
PART-TIME SCHEDULE
It is medically necessary for the employee to work a PART-TIME SCHEDULE due to the employee’s serious health
condition.
Indicate the part-time schedule the employee needs:
Employee can work _____ hours per day for_____ days per week from _______________ through ______________
Section F: Restrictions
(Continued)
Please list restrictions that preclude the employee from performing one or more of his or her essential job functions.
Limit the restrictions to those caused by the serious health condition (Answer after discussing essential job functions
with employee):____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Additional Comments:_______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Section G: Definition of Health Care Provider
Department of Labor regulations for the Family and Medical Leave Act define a “health care provider” as a
a. doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse
practitioner, nurse-midwife, or clinical social worker, physician’s assistant, who is authorized to practice by the
State and performing within the scope of their practice as defined by State law, or a Christian Science practitioner.
b. any provider the employee's group health plan will accept certification of a serious health condition to
substantiate a claim for benefits.
____________________________________________
___________________________________________
(Signature of Health Care Provider)
(Date)
____________________________________________
___________________________________________
(Print Name of Health Care Provider)
(License No.)
____________________________________________
_____________________________________________
(Address)
(Phone No.)
Thank you for your assistance.
DHR FML2 (Rev. 08/2017)