Certification of Health Care Provider
(Family and Medical Leave ACT of 1993)
1. Employee’s Name:
_________________________________________________
2. Patient’s Name (if different from employee): _____________________________
3. The
attached sheet describes what is meant by a “serious health condition” under
the Family and Medical Leave Act. Does the patient’s condition[1] qualify under any of the categories
described? If so, please check the
applicable category.
(1)____ (2)____
(3)____ (4)____ (5)____
(6)____, OR None of the above
_______
4. Describe
the medical facts which support your certification, including a brief statement
as to how the medical facts meet the criteria of one of these categories:
5. a. State
the approximate date the condition commenced, and the probable duration of the
condition (and also the probably duration of the patient’s present incapacity[2] if different): _________________________
5. b. Will
it be necessary for the employee to take work only intermittently or to work on
a less than full schedule as a result of the condition (including for treatment
described in item 6 below)? ___________
If yes, give the probable duration:
______________________________________
5. c. If the
condition is a chronic condition (condition #4) or pregnancy, state whether the
patient is presently incapacitated2 and the
likely duration and frequency of episodes of incapacity2.
6. a. If
additional treatments will be required for the condition, provide and estimate
of the probable number of such treatments:
If
the patient will be absent from work or other daily activities because of
treatment on an intermittent or part-time basis, also provide an estimate of
the probable number and interval between such treatments, actual or estimated
dates of treatment if known, and period required for recovery if any: ______________
_________________________________________________________________
6. b. If any
of these treatments will be provided by another of health services (e.g.,
physical therapist), please state the nature of the treatments: _________________
6. c. If a regimen
of continuing treatment by the patient is required under your supervision,
provide a general description of such regimen (e.g., prescription drugs,
physical therapy requiring special equipment):_______________________
__________________________________________________________________
7. a. If
medical leave is required for the employee’s absence from work because of the
employee’s own condition (including absences due to pregnancy or a chronic
condition), is the employee unable to perform work of any kind?
_____________________________
________________________________________________________________________
7. b. If
able to perform some work, is the employee unable to perform any one of the
essential functions of the employee’s job (the employee of the employer should
supply you with information about the essential job functions)? __________________________________
________________________________________________________________________
If yes, please list the essential functions the employee
is unable to perform:
7. c. If
neither a. nor b. applies, is it necessary for the employee to be absent from
work for treatment?
______________________________________________________________
8. a. If
leave is required to care for a family member of the employee with a serious
health condition, does the patient require assistance for basic medical or
personal needs or safety, or for transportation? ________________________________________________
8. b. If no,
would the employee’s presence to provide psychological comfort be beneficial to
the patient or assist in the patient’s recovery? ___________________________________
8. c. If the
patient will need care only intermittently or on a part-time basis, please
indicate the probable duration of this need:
__________________________________________ ________________________
(Signature of Health Care Provider) (Type of Practice)
__________________________________________ ________________________
(Address) (Telephone number)
To be
completed by the employee needing family leave to care for a family member.
State the care you will provide and an estimate of the
period during which care will be
provided, including a schedule if leave is to be taken
intermittently of if it will be
necessary for you to work less than a full schedule:
_________________________________________ ________________________
(Employee signature)
(Date)
A “Serious Health Condition” means an illness, injury,
impairment, or physical or mental
condition that involves one of the following:
1. Hospital
Care
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.
2. Absence Plus Treatment
(a) A period of incapacity of more than three consecutive calendar days (including any subsequent treatment of period of incapacity relating to the same condition), that also involves.
(1) Treatment[3] two or more time by a health care provider, by a nurse or physician’s assistant under direct supervision of a health care provider, or by a provider of health care services (i.e., physical therapist) under orders of, or on referral by, a health care provider; or
(2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment[4] under the supervision of the health care provider.
3. Pregnancy
Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Conditions Requiring Treatments
(1) 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;
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.)
5. Permanent/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 not be receiving active treatment by, a health care provider. Examples include Alzheimer’s a severe stroke, or the terminal stages of a disease.
6. Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive
multiple treatments (including any period of recovery there from) by a health
care provider or by a provider of health care services under orders of, or on
referral by, a health care provider, either for restorative surgery after an
accident or other injury, or for a condition that would likely result in a
period of incapacity of more than three consecutive calendar days in the
absence of medical intervention or treatment, such as cancer (chemotherapy,
radiation, etc.), severe arthritis (physical therapy), kidney disease
(dialysis).
[1] Here and elsewhere on this form, the information
sought relates only to the condition for which the
employee is taking FMLA leave.
[2] “Incapacity,” for purposes of FMLA, is defined to mean inability to work, attend school or perform
other regular daily activities die to the serious health condition, treatment therefore, or recovery
there from.
[3] 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.
[4] 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 the taking of over-the-counter medications such as aspirin, antihistamines.
or salves: or bed-rest. drinking fluids.