Employee Name:__________________________________ _______________________________________________ _____________ FMLA Claim #: _________________________________
Certifcation o Health Care Provider or Family Member's Serious Health Condition (Family and Medical Leave Act) SECTION I: For Completion by the EMPLOYEE Please complete Section I beore giving this orm to your amily member or his/her medical provider. The FMLA permits an employer to require that you submit a timely timely,, complete, and sucient medical certication to support a request or FMLA leave to care or a covered amily member with a serious health condition. I requested by your employer, your response is required to obtain or retain the benets o FMLA protections. Failure to provide a complete and sucient medical certication may result in a denial o your FMLA request. Your Name:__________________________ Name:_________________________________________________________________ _________________________________________________________________________ __________________________________ First
Middle
Last
Name o amily member or whom you will provide care:_________________________________________________________________ care:_________________________________________________________________ First
Middle
Last
Relationship o amily member to you:_______________________________________________________________________________ you:_______________________________________________________________________________ mm/dd/yy I amily member is your son or daughter daughter,, date o birth:_________________________ birth:________________________________________________________ _______________________________
Describe the care you will provide to your amily member and estimate leave needed to provide care: __________________________________________________________________________ ___________________________________ _________________________________________________________________________ __________________________________ __________________________________________________________________________ ___________________________________ _________________________________________________________________________ __________________________________ __________________________________________________________________________ ___________________________________ _________________________________________________________________________ __________________________________ ___________________________________________________________________ Employee Signature
mm/dd/yy ______________________________________ Date
SECTION II: For Completion by the HEALTH CARE PROVIDER The employee listed above has requested leave under the FMLA to care or your patient. Answer, ully, and completely, all applicable parts below. Several questions seek a response as to the requency or duration o a condition, treatment, etc. Yo Your ur answer should be your best estimate based upon your medical knowledge, experience, experience, and examination o the patient. Be as specic as you can; terms such as "lietime," "unknown," "unknown," or indeterminate" may not be sucient to determine FMLA coverage. Limit your responses to the condition or which the patient needs leave. Page 2 provides or additional inormation, should you need it. Please be sure to sign the orm on the las t page. NOTE TO ALL HEALTH CARE PROVIDERS: The Genetic Inormation Nondiscrimination Act o 2008 (GINA) prohibits employers and other entities covered by GINA Title II rom requesting or requiring genetic inormation o an individual or amily member o the individual, except as specically allowed by this law. To comply with this law, we are asking that you not provide any genetic inormation when responding to this request or medical inormation. ‘Genetic Inormation’ as dened by GINA, includes an individual’s amily medical history, the results o an individual’s or amily member’s genetic tests, the act that an individual or an individual’s amily member sought or received genetic services, and genetic inormation o a etus carried by an individual or an individual’s amily member or an embryo lawully held by an individual or amily member receiving assistive reproductive services. Provider's name and business address:______________________________________________________________________________ address:______________________________________________________________________________ Type o practice / Medical specialty:_________________________________ specialty:________________________________________________________________________ ________________________________________________ _________ Telephone: (
) _______________________ Fax: (
) _______________________
Part A: Medical Facts mm/dd/yy 1) Approximate date condition condition commenced:_____________________ commenced:____________________________________________________________ ____________________________________________________ _____________
Probable duration o condition:_________________________________________________________________________________ condition:_________________________________________________________________________________
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Employee Name: _________________________________________________ FMLA Claim #: _________________________________ Mark below as applicable: Was the patient admitted or an overnight stay in a hospital, hospice, or residential medical care acility? £No £Yes I so, dates o admission: _________________________________________________________________________________________________________ Date(s) you treated the patient or condition: _________________________________________________________________________________________________________ Will the patient need to have treatment visits at least twice per year due to the condition? £No £Yes Was the medication, other than over-the-counter medication, prescribed? £No £Yes Was the patient reerred to the other health care provider(s) or evaluation or treatment (e.g. physical therapist)? £No £Yes I so, state the nature o such treatments and expected duration o treatment: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 2) Is the medical condition pregnancy?
£No £Yes
I so, expected delivery date:
mm/dd/yy
3) Describe other relevant medical acts, i any, related to the condition or which the patient needs care seeks leave (such medical acts may include symptoms, diagnosis, or regimen o continuing treatment such a s the use o specialized equipment): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Part B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient's need or care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, saety or transportation needs, or the provision o physical or psychological care: 4) Will the patient be incapacitated or a single continuous period o time, including any time or treatment and recovery? Estimate the beginning and ending dates or the
£No £Yes
mm/dd/yy mm/dd/yy period o 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: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
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Employee Name: _________________________________________________ FMLA Claim #: _________________________________ 5) Will the patient require ollow--up treatments, including any time or recovery? £No £Yes Estimate treatment schedule, i any, including the dates o any scheduled appointments and the time required or 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 or recovery? Estimate the part-time or reduced work schedule the employee needs, i any:
£No £Yes
___________Hour(s) per day: ___________days per week rom ___________through ___________ Explain the care needed by the patient, and why such care is medically necessary: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 7) Will the condition cause episodic fare-ups periodically preventing the employee rom perorming his/her job Functions? Is it medically necessary or the employee to be absent rom work during the fare-ups? £No £Yes I so, explain:
£No £Yes
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Based upon the patient's medical history and your knowledge o the medical condition, estimate the requency o fare-ups and the duration o 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 YOUR ADDITIONAL ANSWER. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
Page 3 o 4 HCPC-FML (01/11) eF
Employee Name: _________________________________________________ FMLA Claim #: _________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
_________________________________________________________________ Health Care Provider Signature Please return to the employer's FMLA administrator at:
Page 4 o 4 HCPC-FML (01/11) eF
mm/dd/yy _____________________________________ Date
MetLie Disability P.O. Box 14590 Lexington, Kentucky 40511 Fax: 1-800-230-9531
