Get Cornell University Personal Medical Leave Provider Verification Form 2021

Filling out the Cornell University Personal Medical Leave Provider Verification Form is an essential step for employees seeking medical leave. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to effectively complete the verification form

1. Click the ‘Get Form’ button to access the Cornell University Personal Medical Leave Provider Verification Form and open it in your preferred editing tool.
2. Begin with Part I of the form, which must be completed by you as the employee. Fill in your full name, employee identification number (EMPLID), job title, department, and both your work and home telephone numbers.
3. In the section labeled 'Employee’s essential job function,' describe your primary job responsibilities clearly to provide context for your medical leave request.
4. Read the statement regarding the Medical Leaves for Staff policy carefully. Your signature below indicates your understanding of these provisions. Date the form as well.
5. Next, Part II must be completed by your health care provider. They should fill in the patient's name and provide medical details as requested in Part A, including the approximate date the condition commenced, probable duration of the condition, and whether hospitalization occurred.
6. The health care provider will need to indicate whether they have prescribed medication, referred the patient to other providers, and provide any necessary details about treatment and follow-ups.
7. In Part B, the health care provider needs to outline the amount of leave required and any anticipated scheduling, including estimated dates for incapacity or part-time work.
8. Completing Part C involves the health care provider including their name, specialty, contact information, and their signature with the date.
9. Once both parts of the form are completed and signed, ensure you return the document to Human Resources within the specified time frame of 15 days from when you receive the eligibility letter. You can either save your changes, download a copy, print it for your records, or share it as needed.

Complete your documents online efficiently by following these instructions and ensuring all required information is provided.