Get To Be Completed By Employee To Be Completed By Health Care ... - Usnh

Filling out the To Be Completed By Employee To Be Completed By Health Care ... - Usnh form is a crucial step in requesting medical leave or care for a family member. This guide will provide you with clear, step-by-step instructions to help you complete the form effectively online.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. In section 1a, enter your employee information, including the last four digits of your social security number, your full name, home address, and USNH department.
3. If your leave request is for the care of a family member, complete section 1b by providing the relationship to the employee, the patient's name, and a brief description of the care you will provide along with an estimated period for the leave.
4. Move to section 2, which must be completed by a health care provider. They will fill out sections 2a through 2e for a medical condition of the USNH employee, or sections 2f and 3 if the condition is related to a family member.
5. In section 2a, the health care provider will indicate whether the patient’s condition qualifies as a serious health condition and will check applicable categories.
6. The health care provider will detail the medical facts in section 2b, explaining how the patient’s condition meets the criteria of serious health conditions.
7. In section 2c, the health care provider will provide dates related to the condition's commencement, work stoppage, return to work, and estimated duration.
8. If applicable, in section 2d, the health care provider will outline any required treatments, including the frequency and types of treatments necessary for the patient.
9. Section 2e will involve the health care provider stating the employee's ability to perform work in light of the medical condition.
10. If leave is for family care, section 2f must be completed, indicating whether the patient requires assistance and describing the duration of such need.
11. Finally, both the health care provider and the employee must sign and date the form in section 3, authorizing the release of information.
12. After completing the form, you can save changes, download the completed document, print it, or share it as necessary.

Take the next step in your process by completing your forms online.