Form CFN552-0755 "Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act)" - Iowa

What Is Form CFN552-0755?

This is a legal form that was released by the Iowa Department of Administrative Services - a government authority operating within Iowa. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2011;
  • The latest edition provided by the Iowa Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFN552-0755 by clicking the link below or browse more documents and templates provided by the Iowa Department of Administrative Services.

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Download Form CFN552-0755 "Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act)" - Iowa

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Certification of Health Care Provider for Employee’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 due to a serious health condition to submit a medical certification issued by the
employee’s health care provider. Please complete Section I before giving this form to your employee. 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 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.
Employer name and contact:
_______________________________________________________________________
Employee’s job title:
____________________________
Regular work schedule:
__________________________
Employees’ essential job functions:
__________________________________________________________________
_________________________________________________________________________________________________
Check if job description is attached:
SECTION II: For Completion by the EMPLOYEE:
Instructions to the Employee:
Please complete Section II before giving this form to your 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 due to
your own serious health condition. If certification is requested, 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. 20 C.F.R. § 825.313. You must be allowed least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name:
________________________
________________________
________________________
First
Middle
Last
SECTION II: For Completion by the HEALTH CARE PROVIDER:
Instructions to the Health Care Provider:
Your patient has requested leave under the FMLA. Answer, fully and completely, all
applicable parts. 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 employee is seeking leave. Please be sure to sign the form on the last page.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.
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 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.
Provider’s name and business address:
______________________________________________________________
Type of practice/Medical specialty:
______________________________________________________________
Telephone:
(____) ____________________________________
Fax:
(____) __________________________
Page 1 of 4
CFN 552-0755 10/11
Certification of Health Care Provider for Employee’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 due to a serious health condition to submit a medical certification issued by the
employee’s health care provider. Please complete Section I before giving this form to your employee. 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 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.
Employer name and contact:
_______________________________________________________________________
Employee’s job title:
____________________________
Regular work schedule:
__________________________
Employees’ essential job functions:
__________________________________________________________________
_________________________________________________________________________________________________
Check if job description is attached:
SECTION II: For Completion by the EMPLOYEE:
Instructions to the Employee:
Please complete Section II before giving this form to your 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 due to
your own serious health condition. If certification is requested, 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. 20 C.F.R. § 825.313. You must be allowed least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).
Your name:
________________________
________________________
________________________
First
Middle
Last
SECTION II: For Completion by the HEALTH CARE PROVIDER:
Instructions to the Health Care Provider:
Your patient has requested leave under the FMLA. Answer, fully and completely, all
applicable parts. 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 employee is seeking leave. Please be sure to sign the form on the last page.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.
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 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.
Provider’s name and business address:
______________________________________________________________
Type of practice/Medical specialty:
______________________________________________________________
Telephone:
(____) ____________________________________
Fax:
(____) __________________________
Page 1 of 4
CFN 552-0755 10/11
PART A: MEDICAL FACTS:
1. Approximate date condition commenced:
______________________________________________________
Probable duration of condition:
______________________________________________________
Mark below as applicable:
______________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No
Yes If so, dates of admission:
From:
________________________
To:
__________________________
Date(s) you treated the patient for condition:
__________________________________________________________________
No
Yes
Will the patient need to have treatment visits at least twice per year due to the condition?
Was medication, other than over-the-counter medication, prescribed?
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. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list
of the employee’s essential functions or a job description, answer these questions based upon the employee’s own
description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition:
No
Yes
If so, identify the job functions the employee is unable to perform:
_________________________________________________
___________________________________________________________________________________________________________
4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical
facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized
equipment):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Page 2 of 4
CFN 552-0755 10/11
PART B: AMOUNT OF LEAVE NEEDED:
5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any
time for treatment and recovery?
No
Yes. If so, estimate the beginning and ending dates for the period of incapacity:
From:
______________________
To:
____________________________
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule
because of the employee’s medical condition?
No
Yes
If so, are the treatments or the reduced number of hours of work medically necessary?
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:
___________________________________________________________________________________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
__________hour(s) per day; __________ days per week from __________ through __________
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions?
No
Yes
Is it medically necessary for the employee to be absent from work during the flare-ups?
No
Yes
If so, explain:
________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH ADDITIONAL ANSWER.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Page 3 of 4
CFN 552-0755 10/11
ADDITIONAL INFORMATION (Continued)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________
________________________
Signature of Health Care Provider
Date
Page 4 of 4
CFN 552-0755 10/11
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