Get Non-fmla Medical Certification By Physician Or ... - State Of Michigan - Michigan

Filling out the Non-FMLA Medical Certification form is an essential process for employees seeking medical leave from work due to health conditions. This guide provides step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to successfully fill out the Non-FMLA Medical Certification form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin with Section I, which covers authorization to release medical information. Fill in the employee’s name and ID number, as well as the patient’s name. Ensure that the patient or their guardian signs the authorization and includes the date.
3. Move to Section II, where the physician or practitioner certifies the medical condition. The healthcare provider must enter the patient’s name and indicate their relationship to the employee.
4. Provide the required medical details. The healthcare provider should describe the medical facts, including diagnosis and prognosis, which support the need for medical leave.
5. Outline the prescribed treatment regimen. Include details such as the number of visits needed, the general nature of the treatment, and whether referrals to other services are required.
6. Indicate the date the employee is expected to be off work and provide an estimated return to work date.
7. Determine if inpatient hospitalization is required and provide a response.
8. Assess whether the employee can perform the essential functions of their position and provide a clear answer based on discussion with the employee.
9. If the leave request is to care for the patient, explain the type of care the employee will provide and estimate the duration of care needed.
10. Complete the identifying information for the physician or practitioner, including their name, type of practice, signature, date, address, and phone number.
11. Once all sections have been completed, review the form for accuracy, save the changes, and prepare to either download, print, or share the completed form as required.

Complete your Non-FMLA Medical Certification form online today to ensure a smooth application process.