"Certification of Health Care Provider Form for Family Member's Serious Health Condition (Fmla) - University of Alabama, Birmingham"

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Certification of Health Care Provider for
Family Member’s Serious Health Condition
(Family and Medical Leave Act)
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.
Employer name and contact: _____________________________________________________________________________________
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. Failure to provide a complete and sufficient medical certification
may result in a denial of your FMLA request. It is your responsibility to ensure that the health care provider returns the completed
form to you or Employee Health via fax# 205 996-9274 within 15 calendar days of receipt.
Your name: ___________________________________________________________________________________________________
First
Middle
Last
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
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 or
genetic services. Page 2 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: ____________________________________________________________________________
(Please Print)
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: _________________________________________________________________
Revised 02/2016
Certification of Health Care Provider for
Family Member’s Serious Health Condition
(Family and Medical Leave Act)
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.
Employer name and contact: _____________________________________________________________________________________
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. Failure to provide a complete and sufficient medical certification
may result in a denial of your FMLA request. It is your responsibility to ensure that the health care provider returns the completed
form to you or Employee Health via fax# 205 996-9274 within 15 calendar days of receipt.
Your name: ___________________________________________________________________________________________________
First
Middle
Last
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
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 or
genetic services. Page 2 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: ____________________________________________________________________________
(Please Print)
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: _________________________________________________________________
Revised 02/2016
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
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):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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, the time required for each appointment,
the care needed by the patient, and why such care is medically necessary including any recovery period:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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 6 months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency: ______times per ______week(s) ______month(s)
Duration: ______hours or ______day(s) per episode
Does the patient need care during these flare-ups? ______No ______Yes
Explain the care needed by the patient, and why such care is medically necessary: _____________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________
_____________________________
Signature of Health Care Provider
Date
Revised 02/2016

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