Get Fmla Certification Form

FREDERICK COUNTY PUBLIC SCHOOLS Certification of Health Care Provider Family and Medical Leave Act of 1993 This Form Must Be Completed By The Health Care Provider. Forms Filled Out By The Patient/ Employee Will Not Be Accepted. Employee Name Leave Is Required For SELF Please indicate whether this is a n Patient Name if for family member FAMILY MEMBER Initial Certification Recertification If leave is for a Family Member please indicate the relationship between the Employee and the patient include step half and regarded as relationships with the most closely associated relationship Parent Spouse Child Under 18 or Incapable of Self Care Please check the reason for leave Inpatient Care including post-discharge recovery Absence Plus Treatment single episode not expected to reoccur/ require future treatments Chronic Condition multiple treatments/ reoccurring conditions Permanent/Long-Term Condition multiple treatments/ continuing care for non-chronic conditions Pregnancy/Birth/Adoption/Foster Care Placement including postpartum recovery Other specify Nature of Illness/Injury as it relates to the need for FMLA Date Condition/Need for Leave Commenced Probable Duration/ Date Leave Should Terminate Future/Intermittent Absences Required YES NO Anticipated Frequency/Duration of Future Intermittent Absences include any patterns or triggers for leave such as seasonal conditions Complete the below portion only if the leave is required for the Employee s own Serious Health Condition Is Employee unable to perform any of the essential functions of his/her position as stated in writing by the employer Please specify. Full Duty Release Date Is Employee Able To Perform Work Of Any Kind Partial Duty Release Date if applicable If the employee is released for partial duty please indicate the type of work that the employee may safely perform. Indicate any restrictions as specifically as possible next to the type of work employee may be released to. Forms Filled Out By The Patient/ Employee Will Not Be Accepted. Employee Name Leave Is Required For SELF Please indicate whether this is a n Patient Name if for family member FAMILY MEMBER Initial Certification Recertification If leave is for a Family Member please indicate the relationship between the Employee and the patient include step half and regarded as relationships with the most closely associated relationship Parent Spouse Child Under 18 or Incapable of Self Care Please check the reason for leave Inpatient Care including post-discharge recovery Absence Plus Treatment single episode not expected to reoccur/ require future treatments Chronic Condition multiple treatments/ reoccurring conditions Permanent/Long-Term Condition multiple treatments/ continuing care for non-chronic conditions Pregnancy/Birth/Adoption/Foster Care Placement including postpartum recovery Other specify Nature of Illness/Injury as it relates to the need for FMLA Date Condition/Need for Leave Commenced Probable Duration/ Date Leave Should Terminate Future/Intermittent Absences Required YES NO Anticipated Frequency/Duration of Future Intermittent Absences include any patterns or triggers for leave such as seasonal conditions Complete the below portion only if the leave is required for the Employee s own Serious Health Condition Is Employee unable to perform any of the essential functions of his/her position as stated in writing by the employer Please specify. Full Duty Release Date Is Employee Able To Perform Work Of Any Kind Partial Duty Release Date if applicable If the employee is released for partial duty please indicate the type of work that the employee may safely perform. Indicate any restrictions as specifically as possible next to the type of work employee may be released to. Sedentary Medium/Heavy Work Equipment Restriction Light Work Reduced Work Period Length of Time Partial Duty is Anticipated to Be Needed For Signatures and Contact Information Required By All Employee Signature Date Health Care Provider Signature Phone Number Address RETURN UNDER CONFIDENTIAL COVER TO Benefit Compliance Officer 191 South East Street Frederick MD 21701 Fax 301-644-5122 Form must be returned completed and signed 30 days in advance when practical and not more than 15 days after the need for leave has been made known in the case of unplanned incidents.