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Certification of Health Care Provider (WH-380-E FS) for Employee s Serious Health Condition Family and Medical Leave Act SECTION I: For Completion by the EMPLOYER Company Name: Date: Contact Name:.

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Fill out the Provider's name and address. Fill out either the type of practice or specialization. Fill out the phone number and fax number. Assess the condition as it relates to the job description provided by the employer in Section I of the WH 380 E form.

FMLA Form WH-382 Designation Notice There's nothing for you to fill out yourself, but if your employer is using this form to ask for additional information to determine whether your leave request is valid, you'll need to take the steps to provide that information.

The new forms must be submitted to the FMLA Administration Human Resources Share Service Center (HRSSC).

Completing the FMLA Form. Ask your employer to complete Section 1 of the form. Your employer will be required to provide your name, job description, work schedule, and job functions on the FMLA form in Section 1. Fill out Section 2 of the form.

Employees can use FMLA for pregnancy any time they wish during the duration of the pregnancy and for one year after the birth or adoption of the child. The FMLA requires employees to request leave at least 30 days before taking it.

Under the regulations, an employer should request medical certification, in most cases, at the time an employee gives notice of the need for leave or within five business days. If the leave is unforeseen, the employer should request medical certification within five days after the leave begins.

Under the FMLA, a serious health condition is an illness, injury, impairment or physical or mental condition that involves inpatient care (defined as an overnight stay in a hospital, hospice or residential medical care facility; any overnight admission to such facilities is an automatic trigger for FMLA eligibility) or ...

Section 101(11) of FMLA defines serious health condition as "an illness, injury, impairment, or physical or mental condition that involves: inpatient care in a hospital, hospice, or residential medical care facility; or. continuing treatment by a health care provider.

You do not have to tell your employer your diagnosis, but you do need to provide information indicating that your leave is due to an FMLA-protected condition (for example, stating that you have been to the doctor and have been given antibiotics and told to stay home for four days).

This form, like 380-E, requires the employer, employee, and the health care practitioner to complete specific information. Your relative's medical provider must complete the rest of the form with information similar to that required by Form 380-E such as: When did the condition begin.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232