Get Medical Certification Form - City Of Riverside - Riversideca

Filling out the Medical Certification Form is an important step in the process of requesting Family, Medical, Pregnancy Disability, or Military Caregiver Leave. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully fill out your medical certification form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Complete the Employee Information section. Fill in all applicable details, including your name, date, ID number, department, phone numbers, current address, position, name of the eligible family member for whom you are requesting leave, date the leave commenced, and planned return date.
3. In the Medical Release section, authorize the release of any medical information necessary for processing your leave request by signing and dating the form.
4. The Medical Certification for Leave section must be filled out by an eligible health care provider. The provider should indicate the date the condition began and the expected end date of the condition.
5. The health care provider should check the appropriate category that the patient’s condition falls under according to the definitions provided.
6. The health care provider must also provide an explanation of how the employee is unable to perform their job functions or care for an ill family member.
7. For Intermittent Leave or Leave on a Reduced Schedule, the health care provider should indicate if it is medically necessary for the employee to be off on an intermittent basis or to work less than the normal schedule. If yes, they should provide comments and a recommended work schedule.
8. The health care provider must sign and date the form, providing their printed name and office phone number as well.
9. Complete the Medical Certification to Return to Work section, confirming the employee is able to return to work and perform all essential job functions, if applicable.
10. Finally, review all entries for accuracy, save any changes made, and consider downloading, printing, or sharing the form as required.

Complete your Medical Certification Form online today for a smooth process.